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STATE OF NEBRASKA `.:i
<br />WHEN < THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />12/15/2020
<br />LINCOLN, NEBRASKA
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECED£NDSNAME (First, Middle, Last, Suffix)
<br />Lynn Marie Meyer
<br />2. SEX
<br />Female
<br />3202D202 3"
<br />December 6, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Minden, .Nebraska
<br />7. SOCIAL SECt1RITY NI,IMBER
<br />505-72-5155
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME `(if 'not Institution, give street and number)
<br />Bryan Medical Center East
<br />70
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL E Inpatient
<br />❑ ER/Ou patient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH LMo.,''bay, Yn)
<br />January 1:8, 1950
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />ON OR TON OF DEATH (include Zip Code)
<br />L ncofn 58506't
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Lancaster
<br />9c. CITY OR TOWN
<br />Lincoln
<br />I8d. COUNTY OF DEATH
<br />Lancaster
<br />❑ Nospice Faclrlty
<br />Bc.
<br />9d. STREET AND NUMBER
<br />7655 Archer Place
<br />9e. APT. NO.
<br />C101
<br />9f. ZIP CODE
<br />68516
<br />'90INSIDE CITY L)M(T8
<br />YES ❑ NO.
<br />10a."MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Ronny Alan Meyer
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Kenneth Dean Steinkruger
<br />12. MOTHER'S -NAME (First, Middle,
<br />Dorothy May Schmidt
<br />Maiden Surname)',
<br />13. EVER IN U.S ARMEO FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Michelle Meyer
<br />14b. RELATIONSHIP TO DECEDENT`:
<br />Daughter-in-law
<br />15. METHOD OF.DISP;OSITION
<br />❑'Bulini ; ❑Conation
<br />E Crernation ❑ Entombment
<br />❑"Removal " ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.) .,,.
<br />December 8, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Lincoln Cremation Service
<br />CITY /TOWN
<br />Lincoln
<br />STATE
<br />Nebraska
<br />17a. FUNERAL, HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Roper & Sons, Inc.';: 4300 0 Street, Lincoln, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Eller the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal everts such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE(FMa' . alAcute Hypoxic Respiratory Failure
<br />disease of Fondff[on resulting
<br />In death)'
<br />Sequentially list conditions, If
<br />any, leading to the cause listed
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Emurthe UNDERLYING CAUSE C) Infection
<br />(disdain) or inlay that initiated'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Sepsis
<br />the events resulting In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) SARS-CoV-2
<br />17b. Zip Code:.;
<br />6x51©
<br />APPROXIMATE INTERVAL
<br />ons(4io death
<br />Few Days'
<br />onset to death
<br />Few Days
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />Parkinsonism, Hyperlipidemia, Depression
<br />20. IF.:FEMALE
<br />▪ Not pregnant wnhln past:year
<br />❑ Pregnantat tlmeOI death
<br />❑-Not pregnant, but pregnant within 42 days of death
<br />O Not pregnant, but pregnant 43 days to 1 year before death
<br />❑, Unknown it.pregnant within the past year
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />onset to death
<br />Few Days •
<br />onset to death
<br />19. WAS MED1CAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ENO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGSAVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />0.
<br />DATE OF)NJURY (Ma, Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,: etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES :._❑NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221 LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />STATE
<br />TIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 6, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 7. 2020
<br />23c. TIME OF DEATH
<br />12:03 PM
<br />230. To;the boot of my knowledge, death occurred at the time, date and place
<br />at(tl duatothe causes) stated. (Signature and Title)
<br />Sara Bakhtiar, MD
<br />25.; DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 VES:''''"E NO [] PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the peals of examination and/or Investigation, in my opinion death occurredat
<br />the time, date and place and due to the cause(e) stated. (signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />E YES ❑ NO
<br />27 :NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sara Bakhtiar, MD, 2300 S 16th St, Lincoln, Nebraska, 68502
<br />28a. REGISTRAR'S SIGNATURE
<br />cern. Z.�rP'
<br />26b. WAS CONSENT GRANTED?„
<br />Not Applicable if 26a is NO ❑ YES; ENO:'
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 14, 2020
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