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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT.CERTlFIES 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
<br />?SATE OF ISSUANCE
<br />5/2512.2
<br />LINCOLN, NEBRASKA
<br />13
<br />3
<br />202302885
<br />304
<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. CEDENTS NAME ,(First, Middle, Last, Suffix)
<br />Barbara 4o Meyer
<br />4 CITY AND DTATE OIR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505 88,0174
<br />8b.•FACItJTX!AME(#riat institution, give street and number)
<br />The Heritage at Sagewood
<br />Sc. CITY OR TO.NN OF DEATH (Include Zip Code)
<br />Grand )si d 68803
<br />5a. AGE - Lest
<br />(Yrs.)
<br />72;
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d STREETANGINUMBEjt
<br />648E MenIorial Drive
<br />9b. COUNTY
<br />Hall
<br />6b.UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Sa. PLACE OF DEATH
<br />HOSPITAL ❑'Inpatient
<br />❑'ER/Outpatient
<br />❑ DOA
<br />10a, MARITAL$TATUSAT TIME OF DEATH Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHERS -NAME (First, Middle, Last, Suffix)
<br />Roger Otto
<br />13. EVER (NUS: ARMED FORCES? Give dates of service If Yes.
<br />(Yes No,'or',ink.) No
<br />15. METHOD OFDISPOSITION
<br />1 Burial ❑ DoneNFon
<br />•
<br />o,;Crelnatiorn ❑Entombment
<br />0'R1HnovaF ❑Other (Specify)
<br />9e. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 06722
<br />iEATtt.Mta , Day Yr)
<br />May 9. 2023
<br />8. DATE OF BIRTH .(Mo , ay
<br />1rr)
<br />Novembe(28f. .950
<br />OTHER 0 Nursing Home/LTC " 'i Hospice Faculty
<br />0 Decedent's Home
<br />10 Other (SpecIfy)ASSISTED LIVING . •""
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />lob. NAME OFSPOUSE (First, Middle, Last,
<br />Robert A Meyer
<br />12. MOTHEWSMAME (First, Middle, Maiden Surname)
<br />Helen Zimmerman
<br />145. INFORMANT -NAME
<br />Robert A Meyer
<br />18a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />9f. ZIP CODE
<br />68801
<br />$.0)E i TY.UNITS>
<br />C r Oa
<br />Suffix) If wife, give maiden name
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Phillips Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ARI Faiths Funeral Home. 2929 S. Locust Street, Grand Island,; Nebraska
<br />18b. LICENSE NO.
<br />CITY / TOWN
<br />Phillips
<br />CAUSE OF DEATH (See €nstructiorte and examples)
<br />18. PART I. Enterthe chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter tenninal events such as cardiac arrest,
<br />respiratory arrest, orventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATECAUsE(Fiaei _: a)Alzheimer's Dementia
<br />disease or ewe** setting
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Oat conditions, if b)
<br />any, leading to the cause listed
<br />14b. RELA11O10H10 TO DECEDENT:'
<br />Spouse
<br />18(2. DATE (b1o, Da)%r Yr.) ......
<br />May 17x2023
<br />Nebraska
<br />fib. Zip Pode ;.
<br />$88O'1
<br />DUE TO, OR ASA' CONSEQUENCE OF:
<br />miur the uNDP1)th1NO t AUiroitC)
<br />(disetistiar Injury tttat lnitiettei
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />TE INTERVAL
<br />onsettodeatit:
<br />8 Years
<br />onset to death
<br />18. PART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting' in the underlying cause given in PART I.
<br />Diabetes Mellitus Type'2, Hypothyroidism due to Grave's Disease, Hypertension, Migraine headaches, Hyperlipidemia, Vita
<br />D Deficiency
<br />19. WAS MEDICAL EXAMINER':
<br />Vitamin
<br />20. IF FEMALE
<br />plot pregnant wlthln peat year
<br />❑ } regnaruu at time of death
<br />❑ 'sot pregnant; but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />, ❑ Unknown if pregnantwithle the past year
<br />22a.DATE OFINJURY(Mo;:Day, Yr.)
<br />22d. INJURY.AT WORK? ;r
<br />0YES 0 N
<br />22e. DE:
<br />21a. MANNER OF DEATH
<br />Natural Homleide
<br />❑ Accident ❑ #ending InvestigatIea
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />13 Driver/Operator
<br />El Passenger
<br />❑ Pressman
<br />❑ Other (Specify)
<br />onset to death
<br />OR CORONER CONTACTED/
<br />❑ YES:.. ®NO
<br />21e. WAS AN AUTOPSY PERFORM.
<br />❑YES IiNO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />m, Street, factory, office building, construction sib, etC (SpgcIy)'
<br />RIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY: -STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 9, 2023
<br />CITY/TOWNN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />May 16, 2023 11:44 AM
<br />23d Ta lhsbeet of my knowledge, death occurred at the time, date and place
<br />an(': due lathe Eause(s) stated. (aignatut and Title) Kimberly A. Mickels, MD
<br />Bil
<br />t g
<br />STATE ;ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME NCED DEAD•
<br />24e. On the Eaeie of examination and/or Investigation, In my opinion deatit Osttflted at
<br />the time, date end place and due to the causes) stated. (Signature •
<br />arkl Thiel
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES till NO C PROBABLY 0 UNKNOWN ❑ YES Il NO
<br />'I1TL
<br />27. NAME,AND AD ESS OF CERTIFIER (Type or Print)
<br />Kimberly A, Mickeis, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803'
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ yes 0 NO
<br />28b. DATE FILED BY REGIS
<br />May 18, 2023
<br />
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