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<br />V*99V THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA
<br />IT CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHK
<br />2. SEX
<br />3. DATE OF DEATH tMondr. Day. Yawl
<br />Donald Herbert Meredith
<br />Male
<br />July 24, 1996
<br />c�
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<br />UNDER I YEAR
<br />_�
<br />-�
<br />a
<br />(Yrs.' 73
<br />May 24, 1923
<br />a
<br />C D
<br />7. SOCIAL SECURTIY NUMBER
<br />arnN
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<br />HOSPITAL ❑ hi Ghent OTHER: IN Nursing Home
<br />27s. DATE OF DEATH (MO.. Day. Yr)
<br />❑ ER OutpansM ❑ Residence
<br />C/)
<br />St. Francis Skilled Care Center
<br />❑ DOA ❑ DOW(Specilla
<br />`
<br />Bd. INSIDE CITY LIMITS
<br />Q T
<br />Ti
<br />I Yee © No ❑
<br />1�
<br />\�
<br />9b. COUNTY
<br />9c, CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (kncktdilp Zp Cods/
<br />i
<br />�a
<br />,..
<br />Grand Island
<br />424 E. 16th 68801
<br />Y. ® No ❑
<br />10, RACE - (e.g., While. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, atcl
<br />r M
<br />13. NAME OF SPOUSE (k'wnb. give nwA*n rwnal
<br />e1`.) ISPe t
<br />White
<br />(Specify) American
<br />r A
<br />CCD
<br />14a. USUAL OCCUPATION (Give kindo,wwork done during most
<br />F--�
<br />Cn
<br />of waknrg his, even Aretrredl
<br />Truck Driver
<br />Moving & Storage Company
<br />N
<br />:;K
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Harry NMN Meredith
<br />Louise NMN Schnittger
<br />D
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<br />V*99V THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA
<br />IT CERTIFIES THE BELOW TO BE A TRUE COPY OF AN ORIGINAL
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHK
<br />ITffVWA "XMff_OFHEALTH,
<br />QFAD-ON FILE 1WR4NE STATE
<br />'=_H�_ ALPO ~Y FOR
<br />VITAL RECORDS. `
<br />DATE OF ISSUANCE 200400168
<br />_ _-
<br />AUG 51996 _ 4STA _ SZOOPER
<br />ASSISTANir.S191I4A ISTRAR
<br />LANCOLN, NEBRASKA NEBRASIK4•DC�J171'ZCHEALTH
<br />STATE OF NEBRASKA - DEPARTMENfQlkl$ALti;aE_
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
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<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH tMondr. Day. Yawl
<br />Donald Herbert Meredith
<br />Male
<br />July 24, 1996
<br />c�
<br />n co
<br />UNDER I YEAR
<br />UNDER 1 DAY
<br />-�
<br />O -!
<br />(Yrs.' 73
<br />May 24, 1923
<br />5b. MOs. I DAYS
<br />C D
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />499 -14 -4222
<br />HOSPITAL ❑ hi Ghent OTHER: IN Nursing Home
<br />27s. DATE OF DEATH (MO.. Day. Yr)
<br />❑ ER OutpansM ❑ Residence
<br />8b. FACILITY - Name (snot vn,OY iocim 9" strew end number)
<br />St. Francis Skilled Care Center
<br />❑ DOA ❑ DOW(Specilla
<br />`
<br />Bd. INSIDE CITY LIMITS
<br />Q T
<br />Ti
<br />I Yee © No ❑
<br />1�
<br />T7 -_
<br />9b. COUNTY
<br />9c, CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (kncktdilp Zp Cods/
<br />9e. INSIDE CRY LIMITS
<br />Nebraska
<br />,..
<br />Grand Island
<br />424 E. 16th 68801
<br />Y. ® No ❑
<br />10, RACE - (e.g., While. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, atcl
<br />r M
<br />13. NAME OF SPOUSE (k'wnb. give nwA*n rwnal
<br />e1`.) ISPe t
<br />White
<br />(Specify) American
<br />r A
<br />CCD
<br />14a. USUAL OCCUPATION (Give kindo,wwork done during most
<br />F--�
<br />Cn
<br />of waknrg his, even Aretrredl
<br />Truck Driver
<br />Moving & Storage Company
<br />N
<br />:;K
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Harry NMN Meredith
<br />Louise NMN Schnittger
<br />D
<br />19a. INFORMANT - NAME
<br />(VeYESunk) (WWII 2/1343 - ) 12/20/45
<br />p
<br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP' - - - -
<br />24 E. 16th, Grand Island, Nebraska 68801
<br />20. BALMER •SIGNATURE d LICENSE NO.
<br />O
<br />co
<br />c. CEMETERY OR CREMATORY - NAME
<br />Burial ❑ Ramoval
<br />(1)
<br />ITffVWA "XMff_OFHEALTH,
<br />QFAD-ON FILE 1WR4NE STATE
<br />'=_H�_ ALPO ~Y FOR
<br />VITAL RECORDS. `
<br />DATE OF ISSUANCE 200400168
<br />_ _-
<br />AUG 51996 _ 4STA _ SZOOPER
<br />ASSISTANir.S191I4A ISTRAR
<br />LANCOLN, NEBRASKA NEBRASIK4•DC�J171'ZCHEALTH
<br />STATE OF NEBRASKA - DEPARTMENfQlkl$ALti;aE_
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
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<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH tMondr. Day. Yawl
<br />Donald Herbert Meredith
<br />Male
<br />July 24, 1996
<br />♦. CRY AND STATE OF BIRTH (ano(in USA.. name courtly)
<br />SDI. AGE - Last BW day
<br />UNDER I YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH 1~. Day. Yawl
<br />Nebraska City, Nebraska
<br />(Yrs.' 73
<br />May 24, 1923
<br />5b. MOs. I DAYS
<br />5c. HOURS "I's
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />499 -14 -4222
<br />HOSPITAL ❑ hi Ghent OTHER: IN Nursing Home
<br />27s. DATE OF DEATH (MO.. Day. Yr)
<br />❑ ER OutpansM ❑ Residence
<br />8b. FACILITY - Name (snot vn,OY iocim 9" strew end number)
<br />St. Francis Skilled Care Center
<br />❑ DOA ❑ DOW(Specilla
<br />Bc. CITY. TOWN OR LOCATION OF DEATH
<br />Bd. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />I Yee © No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c, CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (kncktdilp Zp Cods/
<br />9e. INSIDE CRY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />424 E. 16th 68801
<br />Y. ® No ❑
<br />10, RACE - (e.g., While. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian. Mexican. German, atcl
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (k'wnb. give nwA*n rwnal
<br />e1`.) ISPe t
<br />White
<br />(Specify) American
<br />NEVER DIVORCED
<br />Annie Brabander
<br />14a. USUAL OCCUPATION (Give kindo,wwork done during most
<br />14b. KIND OF BUSINESS INDUSTRY
<br />I 15. EDUCATION iSp-dy onty highest grads CompWOM
<br />of waknrg his, even Aretrredl
<br />Truck Driver
<br />Moving & Storage Company
<br />I Eernontary og dary 4wr (0.12) ' C~ It -a or 5.1
<br />tS -
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Harry NMN Meredith
<br />Louise NMN Schnittger
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(VeYESunk) (WWII 2/1343 - ) 12/20/45
<br />Annie Meredith
<br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP' - - - -
<br />24 E. 16th, Grand Island, Nebraska 68801
<br />20. BALMER •SIGNATURE d LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21 b. DATE 24
<br />c. CEMETERY OR CREMATORY - NAME
<br />Burial ❑ Ramoval
<br />July 26, 1996
<br />Hill Cemetery
<br />22a. FUNERAL HOME - NAME
<br />21 it CEMETERY OR CREMATORY LOCATION - CITY OR TOWN STATE
<br />Livingston- Sondermann F.H.
<br />❑x^a0on ❑Donakon
<br />Omaha, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) '-
<br />505 West Koenig, Grand Island, Nebraska 68801
<br />0
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. Ib', AND IQ I rarYal between onset and death
<br />PART
<br />x
<br />Ia'
<br />DUE TO, OR AS A CONSEOUENCE OF I Interval bstwesn or" rd death
<br />e I
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE Q - dwT and ds�fi - -
<br />I I
<br />I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />PART PREGNANCY
<br />II
<br />111 IF FEMALE. WAS THERE A
<br />IN THE PAST 3 MONTHS?
<br />24 AUTOPSY
<br />X
<br />25. WAS CASE REFERRED TO MEDICAL
<br />)4 EXAMINER OR CORONER?
<br />il' L�l//�% ,i•
<br />(Ages 10-54) Yes NO
<br />Yes No
<br />Yes .
<br />25L
<br />26b. DATE OF INJURY (MO.. Day. Yr./
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />E] A-- E] UfxWWn kted
<br />❑ Suields ❑ Pending
<br />❑ Hpntcde knos grion
<br />M
<br />260. INJURY AT WORK
<br />Yea ❑ No ❑
<br />261. WC=.0 -( Mlfro, farm, street factory
<br />d66cc SOac�'1
<br />26g. LOCATION - STREET OR R.F.D. NO. CRY OR TOWN - STATE
<br />27s. DATE OF DEATH (MO.. Day. Yr)
<br />28s. DATE SIGNED I11111o. Day. n)
<br />28b. TIME OF DEATH
<br />a
<br />Ili
<br />E
<br />X July 24, 1996
<br />8
<br />a
<br />M
<br />27o July 25 Day. 1996
<br />�, Y
<br />270. n7:20 D DEATH M
<br />lil�l M
<br />28c. PRONOUNCED DEAD- {AID.. Day, Yil
<br />Md. PRONOUNCED DEAD (How)
<br />M
<br />27d. To the beat of my knowledge, death��°5�+��ed r the lime, dale and ptx due to Ihe
<br />se(s) stated. /
<br />280. On one basis of examirtationandror
<br />the tirtle. date and �sa9so(s) t ed opinion death ottunW at
<br />place and due or dw uuatio stated.
<br />S- nature and title
<br />tore and Tale
<br />29. DID TOBACCO
<br />USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />jov ❑ YES 1:1 NO UNKNOWN ❑ YE5 NO
<br />3D.b WAS CONSENT GRANTED?
<br />ly- ❑ YES 9T NO
<br />. �..w.c N.0 nuuncaa yr �,cn i inch Irm J4.1/•IY, ta»amtn a rnr�lnn tlR t:uuly I T A n wnntT I / r ype a rnnq
<br />X Jane A McDonald, MD, 800 A pha Street, Grand Island Ne 68803
<br />32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (W... Day. Ycl
<br />..,.� AUG 11996
<br />
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