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<br />STATE OF_NEBRASKA
<br />'st%(ll'Wiliilittaa
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A 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
<br />DATE OF ISSUANCE
<br />5/4/2023
<br />LINCOLN, NEBRASKA
<br />202302326
<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 />1. DE 3ENDS-NAME (First, Middle, Last, Suffix)
<br />David Allen Meyer
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Fullerton, Nebraska
<br />7. SOCIAL SECURI
<br />506.66-6117
<br />NUMBER
<br />8b."FACILi1Y=NAME (Jtlint institution, give street and number)
<br />CHI Health St. Francis
<br />sc. : cavort TOWN
<br />Grand island
<br />OF DEATH (Include Zip Code)
<br />68803
<br />9a' RESIDENCE -STATE
<br />Nebraska
<br />Sd.,STRE1T ACID NUMBER
<br />431 T Michigan Av
<br />5a. AGE . Laet:Birthday.
<br />(Yrs.)
<br />71
<br />Mx:UNDER UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITALInpatient
<br />❑ ER/Outpatient
<br />❑DOA
<br />N. COUNTY
<br />Hall
<br />Ioa:AIARITALSTATUS AT TIME OF DEATH Married 0 Never Married
<br />0 Married, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />11. FATHER'S -NAME (first,
<br />Wiilianl Meyer
<br />Middle, Last, Suffix)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) ND
<br />15. METHOD OF DISPOSITION
<br />a:Burial ❑Donation
<br />❑'0refftat[oi► ❑ Entombment
<br />❑ Removal ❑ Other• (Spfy)
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />2105974
<br />3. DATE
<br />ADril 20, 2023
<br />6. DATE OF BIRTH:(Mo., Days'( r )`
<br />July 14, 1
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedents Home
<br />❑ Other (specify)
<br />ISd. COUNTY OF DEATH
<br />Hall
<br />1
<br />Pa APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Sg IN loso)TYLtMIT
<br />YEB
<br />("NOT
<br />1ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Barbara Judge
<br />14a. INFORMANT -NAME
<br />Barbara Meyer
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />12. MOTHER'S -NAME (First, Middle,
<br />Jessie Sinsel
<br />16b. LICENSE NO.
<br />1092
<br />Maiden Stmtame)`
<br />14b. RELATIONSHIP TO DECEDENTS;
<br />Spouse
<br />16a DATE (Mo., Day, Yr.)
<br />May
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a.'FUNERAL HOME NAME AND MAILING' ADDRESS (Street, City or Town, State)...
<br />Curran Fuberat Chapel, 3005 S. Locust St., Grand Island, Neebraska;
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See Ins uctions and examples)
<br />18. PART 1. Enter the chain of events- decease, injuries, or complications4hatdirectly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing t the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUL (Fin.( a) subdural hematoma
<br />disease or Condition•
<br />reauiting
<br />M depth) ....
<br />Sequentially list Conditions, If
<br />any, leading to the cause listed
<br />on.hnee •
<br />Enter the UNDERk;YYNO CAUS1
<br />(disease or In)ury that laitiatsd
<br />the events resulting in death).
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)thrombocytopenia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) myelodysplasia syndrome
<br />STATE
<br />Nebraska
<br />176.
<br />68801``.
<br />APPROXMPATE INTERVAL
<br />i onset.%depltt'
<br />HOure :..
<br />onset to death,
<br />Months
<br />Ye,
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PARTN, O'VHERSIONIFICANT'CONDITIONS-Conditions contributing to the death but not rem
<br />20.1F FEMALE:..
<br />Not PMgna' wittOn past veer
<br />Pregnant at tithe of death
<br />Al01 pregnant; but pregnant within 42 'days of death
<br />❑> Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown If pregnant within the past year
<br />22 ATE OF INJURY (Ma., Day, Yr.)
<br />22d.INJURY ATWORK?
<br />0 YES .[] NO
<br />21a. MANNER OF DEATH
<br />IE Natural ©Homiicide
<br />o Accident ❑ Pending Mimetic
<br />0 Suicide 0 Could not be determined
<br />0
<br />in the underlying cause given in PART L
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY
<br />22e.DESCRIBE HOW INJURY OCCURRED
<br />22E.LOcATiotitiF INJURY: STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 20, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />April 27. 2923
<br />at To the Metof My knowledge, death occurred at the time, date and place
<br />and due to the =kennels) stated. (Signature and title)
<br />Alexander Kaganas, MD
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Ddver/OPerator
<br />IZI Waeenger
<br />Pedestrian
<br />❑ Other (Specify)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER;
<br />ORC NERCoNTAt D?`
<br />❑ YES RI NO
<br />21c. WAS AN AUTOPSYPERPORMED?
<br />a YE$
<br />NO
<br />21d. WERE AUTOPSY" FINDINGS A4tAtlABL:E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES [.No,
<br />t home,farm, street, factory, office building, construction
<br />CITYI'r"QWN
<br />23c. TIME OF DEATH
<br />12:38 AM
<br />25. DID TOBACCO USE CONTRIBUTE TO DEATH?
<br />24a. DATE SIGNED (Mo., Day, Yr)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH ' l`
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination end/orInvestigation, in my opinion datum p t it ep.
<br />;tlutbne date and place and due to the cause(e) stated (Signature eal$7iee)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES WHO::
<br />jYES ❑ NO 0 PROBABLY UNKNOWN
<br />27. NAME, Tine AND ADDRESS OF CERTIF ER (Type or Print i
<br />AexanderKaganas, MD, 2621 W Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED? ..
<br />Not Applicable if 26a is NO ..:1:31E41
<br />0
<br />NO
<br />28b. DATE FILED BY REGISTRAR (Mo., DayYr.)
<br />May 3, 2023
<br />
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