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<br />WHEN THIS COPY CARRIES THE RAISED SEAL. OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL. RECORD ON FILE WITH THE NEBRASKA < DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />LINCOLN, NEBRASKA
<br />'I. QECE1lEND I -NAME 01tat,
<br />Tlrn ttty 'Vail Mieyer'
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<br />202`06512
<br />SARAH BOHNENKAMP f
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />ddle, Last, Suffix)
<br />CERTIFICATE OF DEATH
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />rh.
<br />St. Paul, Nebras
<br />y. SOCIAL SECURITY NtUMBER
<br />.508-88.0385
<br />8b. FACILITY -NAME { Institutor', give street and number)
<br />CHI Health St.. Francis
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />I T1nd Island 88803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />STREET AND NUMIIGER
<br />4249 Pennsylvania Anvenue
<br />5a. AGE Last:Birthday
<br />(Yrs )
<br />5b UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />1 6s PLACE o1:DEAT4
<br />HOSPITAL f tnpaatient
<br />ER/Ou patient
<br />❑ DOA
<br />DAYS
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married
<br />0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />11. FATHER'S•NAME (F)rdt, Middle, Last, Suffix)'
<br />Henry Robert Meyer
<br />13.'EVERIN U3.: ARMEO FORCES? ,Give dates of service If Yes.
<br />(Yea, bio, or unk.) Yes 12/2111977-12/31/1997
<br />15. METHOD OF DISPOSITION
<br />D Bursal UDon tion
<br />(:Crettta5o11❑Entamlement
<br />I 'Rtmtovat ;< ❑ Other {Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEAT'H;1
<br />Mev 11,
<br />2022P:.
<br />4•,135y 4
<br />6. DATE OF FIRTH. Mo., DaypYti)
<br />OTHER 0 Nursing HomeILTC
<br />❑ Decedent's Hartle
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CQDE
<br />68803
<br />I plc4 Faoiiky
<br />J
<br />10b. NAME OF SPOUSE (First Middle, Last, Suffix) If wife, give midden name
<br />Sheltie Wulf
<br />14a. INFORMANT -NAME
<br />Shellie MeyerWife
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />12. MOTHER'S -NAME (First, Middle,
<br />IlE M/ Jane Johnson
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />ITa. FUNERAL,k1OME NAME AND A LING ADDRESS (Street, City or Town, State)
<br />Apfel f=uneral (•torte, 112 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1537
<br />CITY / TOWN
<br />Gibbon
<br />14b. REI ATIONS IUP TO DEBEDENT;•
<br />180. DATE (Mo
<br />Mav 22, 2t
<br />CAUSE OF DEATH (See irtstrut takna and examples)
<br />18. PART 1. Enter the chain of events- diseases, 'Nudes, or complketlons4hat directly caused the death. DO NOT enter tennlnal events such es cardiac arrest,
<br />respiratory arrest, or ,antricular nbddatton without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H necessary.:
<br />IMMEDIATE CAUSE:
<br />a) Acute febrile illness
<br />IMMEDIATE CAU . (final
<br />dlaasse or41in4lt 1Ni resuklog
<br />in depth)
<br />Sequenttatylist Conaiaons, 81
<br />DUE TO, ORAS Ai;CONSEQUENCE OF:
<br />b) Urinary tract infection
<br />any, leading to the cause Uared
<br />en Enna.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />,:Yr-) .
<br />$TATE
<br />1lNebraska
<br />17k4Code
<br />t8C1
<br />APPROXIMATE INTERVAL
<br />onset te1
<br />(dl9ea5e dr it�uly3ttat Ittiltetal
<br />the events resulting in dug') c DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18 PART II, OT1iER SIGNI ICANT CONDITIONS
<br />CheSt pain
<br />20. IF FEMALE
<br />Not pregnene within esat year.
<br />Pregnantattl esarrttaea•:
<br />ttet pregnoati but pregnant within 42 days of death
<br />❑ Not,pregnant, but pregnant 43 days to 1 year before death
<br />❑ .Unknown 11pregnantwahin the pent year
<br />onset to death
<br />onditlons contributing to the death but not resuitingIn the
<br />22a. DATE OF INJURY Day, Yr.)
<br />22d. INJURY AT WORK? . DESC
<br />❑YES 0 N
<br />2
<br />21a. MAN O. DEATH
<br />® Natural ❑ HomtCtde
<br />❑ Accldem ❑ !e•°411'9Imresagatt •
<br />❑:Suicide 0 Could not be det►mtinad •
<br />22b. TIME OF INJURY
<br />derlying cause given In PART I.
<br />2111. IF TRANSPORTATION INJURY
<br />0 DrluarlOperator
<br />0 Passenger
<br />❑ Pedestrian
<br />'.,❑
<br />Other (Specify)
<br />19. MS MEtIICAL':EXA1 MNE1
<br />OR CORONSW.00NTASTS
<br />J vas ONO
<br />210. WAS AN A. t+E1
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑: NO
<br />22c. PLACE OF INJURY At home,` farm, street, factory, office building, construction site,
<br />RIBE HOW INJURY OCCURRED
<br />22f LOCATION OF IN.WRY;. STREET & NUMBER,.APT.NO. •
<br />•
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 17, 2022
<br />3P. DATE SIGNED (Mo., Clay, Yr.)
<br />flay 19 2022
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />12:28 AM
<br />tad, TA Iha bast.:of my knowledge, death occurred at the time, date and place
<br />soil cin tothe:oause(s) stated. (Signature and Title)
<br />Patrick George Woods, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME:
<br />24e. On the bailie of examination andfor Imesagatlon, th my Welk pd'n
<br />fee floe, date and place and due to the causes) s sl. Red pas)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES MN()
<br />21 NAME TITLE ItND ADDRESSOF CERTIFIER (Type or Print
<br />2& DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Ind YES ❑ NO ❑ PROBABLY 611 UNKNOWN
<br />Patrick George Woods, MD 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />rB. aL afak J
<br />26b. WAS CONSENT
<br />Not Applicable If 26a Is NO ` .1 rE
<br />ODE, .
<br />28b. DATE -FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 24, 2022
<br />r•
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