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<br />STATE OF NEBRASKA
<br />lrii1111111a`..;rdl ))�
<br />IIIINI
<br />U CHIS COPY CARRIES THE RAISED SEAL. OF STATE OFNEBRASi .A, IT CERYIPI>I S THE DOCUMENT BELOW TO
<br />A TRR.UE COPY OF T HE ORIGINAL RECORD ON FILE WITH THE NEMASiA DEformENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUAN'i`CE
<br />6/312022
<br />UNCOLN, NEBRASKA
<br />20'230`4425
<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 />Middle, Last, Suffix)
<br />POW 44tift Meer
<br />0. C)TYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebr.at
<br />day 'rab UNDER 1 YEAR
<br />sOCIAI SEOUreTYINetkaaaR
<br />.8.0740-01B6
<br />Sb. FACILITY-NIME (If not Institution, give street and number)
<br />o
<br />CHI eal
<br />Hth Si, Franois HMS
<br />MOS.
<br />DAYS
<br />B3,:PLA4E QP:t E4TH ...
<br />,:Noserrsti.mglopystoot
<br />0 ER/Outpatient
<br />ooh
<br />•kTY Ol T.DWIN O1± D ►TH (include Zip Code)
<br />rand Isii;irld S
<br />a REIIiDENCE.STATE
<br />Nebraskan;
<br />9d, 87'REETR fP siuMBER
<br />4128 Allen): Ave
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />H
<br />RS
<br />MINS.
<br />9b. COUNTY
<br />Hall
<br />10a:MARITADETATODAT TIME OF DEATH ® Married 0 Never Married
<br />0 Married,'but separated.' .0Widowed 0 Otvorced+ 0 Unknown
<br />FATMER'S:-NAial (First, Middle. ' Last, Suffix)
<br />4ovd Denman
<br />13. EYER IN It& ARMED 'FORCES? , Give dates of service if Yes.
<br />(Yes, No, orm)lnlu) No
<br />6.:M.ETH. 0D OF DISPO$I..TION
<br />at Burrs) )JDona on
<br />•Q':Cremadori Entoilbment
<br />:trotemoval Other (SJfy)
<br />17a FtiNERA1,HOME NAME AND MA LING ADDRESS (Street City or Town, Stag)
<br />• I Falthe Funeral llama, 2929 S. Locust Street, Grand Island,<Nebraska
<br />10b. NAME OF SPOUSE (First, Middle, Las
<br />Paul Meyer '
<br />12. MOTHERS -NAME (First, Middle,
<br />Ifiana Herman
<br />9c. CITY OR TOWN
<br />Grand Island
<br />ad. COUN
<br />Hall
<br />Re. APT. NO.
<br />14a. INFORMANT -NAME
<br />Paul Meyer
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />9f. ZIP CO
<br />68803
<br />Suffix) if wife,
<br />16d. CEMETERY, CREMATORY OR OTHER LO
<br />Aida Cemetery
<br />TION
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Alda
<br />CAUSE OF DEATH (Seo iirletrudti Dne end examples)
<br />. PART L Enter dre chain of events,, -diseases, injuries,- or compllcafiona4nat directly caused the death. DO NOT enter terminal events such as cardiac arNpt,'
<br />respiratory wrest, Or ventricular libdlladon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional tunes if necessary
<br />IMMEDIATE CAUSE:
<br />a) ponumonia
<br />1
<br />sec. DATE
<br />May 26.2
<br />. JE TO, OR AS' A CONSEQUENCE: OF:
<br />sequentiallydra condition, it b)mantle cell lymphoma
<br />any,IaadIng to the-cauae Naleu
<br />online a
<br />PART1(
<br />FTHEIt SIt3N4F`I+
<br />TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />def
<br />CONDITIONS -Conditions conhtbuting to the death bili not ra
<br />Mt'
<br />or death;:
<br />❑ "`Nan but pregnant within 42 days of death
<br />i N„„&e°111.1t regnant,bi*ptgneat 43 days to 1 year before death
<br />. unknown if pratfall peet]nor
<br />4.F
<br />22d. INJURY AT WORK?
<br />0 YES JQ NO..
<br />21a. MANNER OF DEATH
<br />Natural Q Hon nude
<br />© Acctdont ❑ Pending Invectttmtten
<br />❑ 8ulcide
<br />0 Codtd not be dabrmined
<br />oIli.1g<.in the
<br />22b. TIME OF INJURY
<br />22c. PLAGEOF el
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f ;t 0CATK±N QF I IJ#JRY -{t
<br />NUMBER, APT.NO.'
<br />23a. DATE OF TH (Mo., Day, Yr-)
<br />2'
<br />ciTYrrouiWN
<br />RY
<br />inderlying
<br />In PARI' I
<br />21,00F TRANSPORTATION INJURY
<br />[2,000/Operator
<br />❑. P 4enger
<br />Pedestrian
<br />0 Odtec(specity)
<br />21
<br />hr�me, farm, street, faotery, office bul)din
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />23c, TIME OF DEATH
<br />09,E
<br />TOMO efai
<br />atYdd due ihe' stated. (Signature and'itieq
<br />•
<br />,.death oceunee at the time, date and place
<br />nder Kaianes, MD
<br />6. DID T. ::...USECONTRIBUTE TO THE DEATH?
<br />YES 61 N#2 PROBABLY 0 UNKNOWN
<br />7 ",.. 11.40iTIT4G4N0.Ari„dO CERTIFIER (Type or Print
<br />Attain*Iagallas, MD, 2621 W Faid(ey ue,
<br />a. REGIS? SIGNATURE
<br />26a. HAS ORGA
<br />❑ YES
<br />249. PRQNOUNCED DEAD (Ma., Day, Y
<br />0a the brans of aundnedon andtor
<br />*titbit.; date and piece and des lb Its
<br />TISSUE DONATION.EEN CONSIDERED?
<br />RO
<br />ka. 68803
<br />4
<br />
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