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<br />STATE OF NEBRASKA
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<br />WHEN THIS OCPY CARRIES THE RAISED SEA;, OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF.:ThIE ORIGINAL RECORD ON FILE WITH THE NEBRASKA: DEPARTMENT OF HEALTH AND
<br />HUMAN SER)1'IaES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />:DATE OF ISSUANCE
<br />6/3/2022
<br />LINCOLN, NEBRASKA
<br />20250091:
<br />202304425 - RAH BONENKAMPs�
<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:OEATH
<br />ECEDENY'S-NAME (First, Middle, Last; Suffix)
<br />MI Me er
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITYNUMBER
<br />$O74O-0166
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI:; Health St. Francis HMS
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 683
<br />9a. RESIDENCE -STATE 9b. COUNTY
<br />Nebraska Hall
<br />9d,.:STRSET AND NUMBER:
<br />4.128 Allen Ave •
<br />10a. MARITAL STATUS AT TIME. OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (F('st, Middle,; Last, Suffix)
<br />Ll©vd ;Denman ;;
<br />13. EVER IN U.S ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />5a. AGE - Last Birthday tSb. UNDER 1 YEAR
<br />(Yrs.)
<br />MOS.
<br />• 69
<br />DAYS
<br />8a:PLACE QF pEATH
<br />HOSPITAL: ❑ Inpatient
<br />❑ ERJOu patient
<br />❑ 0OA.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />22 07499
<br />3. DATE OF DEATH(Mo., Day, Yr):
<br />May 21, 2022
<br />6. DATE OF BIRTH (Mo., Day Yr.)
<br />March 30,.1.953<>
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9f. ZIP CODE
<br />68803
<br />❑ Hospl. a Facility
<br />9g,:.INS(bE CITY LIMITS..>:
<br />;YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Paul Meyer
<br />14a. INFORMANT -NAME
<br />Paul Meyer
<br />12, MOTHER'S: -NAME (First, Middle, Maiden Surname)
<br />Hilrne Herman
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />w [ Burial ❑ Donation
<br />Crematiois ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />e
<br />0
<br />is
<br />0.
<br />•: 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES .. NO ❑ PROBABLY ❑ UNKNOWN
<br />27. NAME,1'(Tkt AND ADDRESS OF CERTIFIER (Type or Print
<br />Alexander Kaganas, MD, 2621 W Faidley Avenue, Grand Island, Nebraska, 68803
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Aida Cemetery
<br />17a. FUNERAL.HQME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths'Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Aida
<br />. CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events -di , Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAt1SE (Figal a) penumon is
<br />diaeiL}a or condition rasultintt
<br />in death) DUE TO, OR AS A CONSEQUE ,CE OF:
<br />Sequentially list conditions, if b) mantle cell lymphoma
<br />any, leading to they cause listed
<br />online a
<br />Enter the uNDERLYING CAUSE•
<br />(disease Or injury that Initiated
<br />the events resulting in death)
<br />LAST
<br />18c. DATE (Mo, Da Yr.)
<br />May 26, 2022
<br />STATE
<br />Nebraska
<br />17b Zip'Code':::
<br />88801 .:
<br />APPROXIMATE INTERVAL
<br />onsetit0iicioe.:'
<br />Minutes
<br />onset to death
<br />Weeks
<br />DUE '1`O,.OR AS A CONSEQUENCE OF:
<br />0)
<br />onset tocleath
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underf])1Ptg cause given iryPART I.
<br />9. IF FEMALE,
<br />Not pre5nef* anthill past year
<br />© .Pregnant *One or death
<br />❑ 'Not 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 />t2a DATE OF:INJUR((Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES : ❑NQ,..;.
<br />21a. MANNER OF. DEATH
<br />® Natural El Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b IF TRANSPORTATION INJIJ*I'
<br />0 Driver/Operator
<br />❑ Prujsanger
<br />Er Pedestrian
<br />❑ Other (Specify)
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES I NO
<br />21c. WAS AN AUTOPSY PERFORMED ..?
<br />❑ YES .a NO
<br />21d. WERE AUTOPSY FINDINGS AVA1tLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22b. TIME OF INJURY 22c. PAGE OF INJURY At home, farm, street, factory, office building, construction site,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INmiVRY?STREET & NUMBER, APT.NO. CITY/TOWN
<br />A
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 21,, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Ali: 2w2
<br />d, USA beet lg., .enowiedge, death occurred at the time, date and place
<br />aiid due to dietause(s) stated, (Signature and Title)
<br />Alexander Kaganas, MD .
<br />28a. REGISTRAR'S SIGNATURE
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIF CODE
<br />2&. TIME OF DEATH
<br />24d, TIME PRONOUNCED DEAD........
<br />24s. On tho4tsais of examination and/or investigation, in my opinion death!hccurretl at
<br />eleaime, date and place and due to the cause(s) stated. (Signature anti rtfla)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES : ONO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO DYES
<br />❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 31, 2022
<br />
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