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Yhl,�,STATE (1, EBRA$KA_
<br />M7l r N� - /II 11 @ rr 1 11 \ltl 1r1 / Yr r i,1N t\
<br />K - tNiAfD Itlll11M11atDv a 4uP�f v -.. Sri/t11111MMDvw� 17yrgrnlala, > IiilAl)lli1i111).
<br />EN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NER.aSKA, IT CERTIFIES THE DOCUMENT
<br />`A TRUE COPY OF THE ORIGINAL RECORQON FILE WITH THE NEGRASKA DEPARTMENT OF HEALTJi
<br />HUJMAN..SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSIT9RY FOR V11TALRECORDS
<br />4A56uc ...
<br />DAFE c E I$SUANGE
<br />6i3 2022`
<br />LINCOLN, NEBRASKA
<br />202403374
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR.
<br />EPARTMENTOF WEALTH ..
<br />AND 'HUMAN SERVICES
<br />•
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF:. DEATH
<br />. 1 DECE END NAME (Eget, Middle, Lipst, Suffix)
<br />)�eggy Lynn MOeer
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island.:Alalraska
<br />. SQCIA#,:SEOtIRITYNUMDER
<br />807 ?10-01
<br />56' AGE - Last Birthday
<br />(Yrs.)
<br />FACILITY -NAME (If not instltution, give street and number)
<br />CHI Health St Francis HMS
<br />-Sc,:crTY OR: TOPItM t F DEATH (Include Zip Code)
<br />a and Isiend 48803
<br />9a. RESIDENCE -STATE
<br />Nebraska :.
<br />;:STREETAMDNUatBER .;
<br />X128 AfletlAve
<br />MARItAGSTATU9`At nME OF DEATH ® Married
<br />0 Married, but separated ❑W'dowed ❑ Divorced
<br />9b. COUNTY
<br />Hall
<br />❑ Never Married
<br />Unknown
<br />t 1, PATER &IME (Fitist.
<br />Denman
<br />........... ............
<br />, Last, Suffix)
<br />60
<br />b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />UNDER I DAY
<br />MOS.
<br />DAYS
<br />ea PLA E OF pERpi
<br />$OS 'tAL {npatlant
<br />t, ER/Outpatient
<br />DOA:.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />' MINS.
<br />49
<br />3. DATE OF riArH,tMG.,, flay,
<br />May 21, 2022
<br />8. DATE OF BIRTH o.,
<br />OTHER 0 Nursing Home/LTC t1 pLce Petri.
<br />❑ Decedent's Homs
<br />❑ Other (Specify) •
<br />8d. COUNTY OF DEATH
<br />Hal( •
<br />e. APT. NO.
<br />10b. NAME OF SPOUSE (Filet,
<br />Paul Meyer
<br />Middle, Last,
<br />9f. ZIP CODE
<br />68803
<br />Suffix) If wife, give maiden DM*
<br />BE( N$ DECITY ftIN(
<br />12 MOTHER S NAME (First, Middle, Maiden Surname).
<br />H)Ima... Herman.
<br />13. EVER IN U M ARMED FORCES? Give dates of service If Yes.
<br />0, or Link.) NQ .. .
<br />14e INFORMANT NAIN'I
<br />Paul Meyer
<br />•
<br />14b. RELATI
<br />SOou
<br />0
<br />1s MM ET. 00 OF, DISt?4SIT N
<br />�. i>1Ltnel ❑ Ot1iNtlwt
<br />• [ ;Ozemxtlon Q Entomt mgfit
<br />j�`Rlinovat"`' Qitier (Specify)
<br />1tia. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16b. LICENSE NO.
<br />18c. DATE (lMlo,
<br />Matt -26, 2
<br />16d. CEMETERY, CREMATORY OR OT
<br />Alda Cemetery
<br />A
<br />(Street, City or Town,
<br />ust Street, Grand Isla
<br />CITY I TOWN
<br />Alda•
<br />STA
<br />.Nebrtask
<br />Ste
<br />nd, Nebraski
<br />CAUL OFD 'H (See instru(IAns and e4amDles)
<br />eras- -Means, Injuries, or eomaiicItiom4dtat dlreatly caused the death. DO NOT enter terminal events suWli ibterrato ar t,
<br />rtus7tl atwnlrmdu[/niviiriq the NrlSlbrif;'AC--Nt)TAe3bWevwre.i:rrta�unl3 one cause on a,leas.:SdtijiSieiwwi3i,wu-aa:aiscse, r.
<br />0
<br />m
<br />ir.Mt1 AlStAtissRANI
<br />dkgkJM of tataiStod rtlsuk
<br />in
<br />Sequemlalty gat conditions, If
<br />arndae t9 to tits eauaa gated
<br />Emer!lhe:::UNOFRLY.INGCAUSE
<br />(digest" or InJurYMat initiated
<br />the events resulting an death)
<br />LAST
<br />IMMEDIATE CAUSE:
<br />A) penumonla.
<br />1 Ai*OXIMAT
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) mantle cell lymphoma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 :P,RT IL OTHER SLGN(I(CANT CONDITIONS'Condittons contributing to the. death b
<br />20. IF::IffiMAL.IM,..:::
<br />of pregrtsnt wah4n peet;kt er
<br />pnga(Int at t)fife
<br />Nm pregnaltl but'preprlant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before Wath
<br />tbeArioem tf prestuMt WIN..tin the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Hom hlele
<br />0 Accident ❑ Pending inysstlgelwn
<br />0 Suicide ❑ Could not be determined
<br />not resulfirig In the underlying cause given in PART I.
<br />22a DATE QFINAIJRY (MDt Day, Yr.) 22b. TIME OF INJURY 22c. PLACECF IN
<br />22d. INJURY AT WORK? 22e. DESCRIBE HOW INJt*IRY OCCURRED
<br />❑ YES .:;{ NO
<br />LOCATION ::OF fNJUttY : STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.) . ;
<br />Ma 21 2022
<br />23b. DATE SIGNEDIMo., Day, Yr.)
<br />214:IF.TRANSPORTATION INJURY
<br />DrtvttrIOperator
<br />:Q Psasenger
<br />P.Watrlan
<br />❑ Other (Specify)
<br />•
<br />ons.t to dsathi:
<br />M)nutt§s
<br />meet to death
<br />Weeks
<br />onset M death .
<br />19. WAalt MEDKCA1 EXAMI
<br />COROI,_,,,_.
<br />014 NBI9 CONTACTED
<br />❑ YES Ill NO •
<br />21c. WAS AN AUTO
<br />❑ YES ® NO
<br />EDT
<br />21d. WERE AUTOPSY FINDINGS AV
<br />TO COMPLETE CAUSE OF DEA
<br />0 YES • CIAO
<br />URY At home,.:farm, street, factory, office building, to
<br />E
<br />CITY/TOWN
<br />STATE
<br />P
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />DEATit
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME P
<br />Tc (1ta blot of(t)7)::knorl{t!dptl, death occurred at the time, date and place
<br />*red, due tothec*uae(s) sta4 d. (Signature and Title)
<br />Alexander Kagenas, MO
<br />. DID TOBACCO USE CONTRIBUTE TO THEDEATH? 28a. HAS ORGAN, R TISSWE DOf
<br />(21 YES n55 NO M PROBABLY 0 UNKNOWN 0 YES ETNO:
<br />2 .:NAM , TI 'E ND ADDR ?. e F R 1- • pe or - Nnt
<br />Alexander kit arias, MC, 2621 W Faidie Avenue, Grand Island Nebraska 1
<br />• pea (h4 Mala of examination andror investlgaoon, M my opinion
<br />tht tibik date and place and due to the causes) stated. (Signet**
<br />TION BEEN CONSIDERED
<br />28b. WAS CONSENT GRAM
<br />Not ADDlicable if 24a le
<br />28a. REGISTRAR'S SIGNATURE
<br />May 31, 2022.
<br />.,'Day, Y
<br />
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