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• • ..•.•
<br />WHEN TH/STOPY CARRIES THE RAISED SEA? ;OF STATE OF. NEBRASKA trcerirtFtEs THE DOCUMENT BELOW TO
<br />. .
<br />fAEA TRUE copy OF THEJGINAL RECORD ON FILE WITH :THE NEIOEASO:: DEPARTMENT OF HEALTH AND
<br />WOMAN SERMOS, vtrAL R RDS OFFICE, YSIHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />STAtE OF NEBRASKA
<br />DATE OF ISSUANCE
<br />.6/312022
<br />LINCOLN, NEBRASKA
<br />10E06)1•004.9iEl$Irst, Middle, Last, Suffix)
<br />Meer
<br />4. tire AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />2 0 25 0 094 6'
<br />:•••• :••:: • •
<br />•:. •••• •
<br />c3ran land, .Nlearaska
<br />aticiAt.$Ecairy:!.!tsa7matit
<br />.$071-70-0466
<br />8141911641LITVAAME (If not institution, give street sod number)
<br />CHI Healtb St, Francis HMS
<br />80 CITY:OK 10.1010E DEATH (Include Zip Code)
<br />*b. COUNTY
<br />Hall
<br />atilpiOtt$$$:!:
<br />f;$428Alla#AVO:i
<br />19a. tiAmtsd.ii•ATuti,AT TIME.OF DEA914.0 Married 0 Never Married
<br />Ej Married, but separated [3 mord 0 Divorced CI Unknown
<br />4186IKTHER8464EAFirsti Md
<br />2 023:0 4 '4 2 5 Mill 41441-141
<br />S_AH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />2 0 2 5 04121
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF:DEATH
<br />di Last, Aufflx) '
<br />13. EVEIRIN u Give dates of service If Yes.
<br />(Yes, No, or ink.) No
<br />46. 'METHOD OF pall;perner4
<br />14"ttiem Doonation
<br />.;•Ortrtlierpeljen.cor.iiitntre
<br />0 ateleval••••• 'El Other (Specify)
<br />• • .
<br />5d:AGE - Last 13Irthday
<br />(Yrs.)
<br />Ea. PLAea erdeA0
<br />HOSPITAU: lridatient
<br />ft
<br />.:UNDER 1 YEAR
<br />MOS.
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />DAYS
<br />0 ER/Outpatient
<br />pp:
<br />9c. CITY OR TOWN
<br />Grand:Island
<br />90 APT NO Of. ZIP CODE :11400$41/Yomenv
<br />68803 014.14!
<br />106. NAME OF SPOU$E (Mist, Middle, Last, Suffix) If wife, give maiden flan
<br />HOURS
<br />MINS.
<br />14
<br />ttr,'
<br />11:11?(
<br />22 07499
<br />3. DATE OF DEATItiM0 Dili ,
<br />May 21, 2022 .ittt
<br />6. DATE OF BlikTH IBM., Day, •
<br />OTHERJJ Nursing Home/LTO
<br />o Decedent's Home
<br />0 Other (Specify)
<br />ed. COUNTY OF DEATH
<br />I Hall
<br />•
<br />Paul
<br />Meyer
<br />12., MOTHER'S -NAME (First, Middle, Maiden thornane1). : •
<br />. ' ;:i•
<br />Hilma Herman
<br />71
<br />14a. INFORMANT -NAME
<br />Paul Meyer
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Aida Cemetery
<br />1Ta.:FONERALHOOEi1KME AND MAILING ADDRESS (Street, City or Towd:Stata)::
<br />All PalthCEtirteial Home, 2028 S. Locust Street Grand
<br />Nebraka
<br />16b. LICENSE NO.
<br />CITY/TOWN
<br />Aida
<br />CAUSE OF DEATH (See instructions and exiimolet)
<br />I. PART L triter the cillibt ot.v�ts. -ogees**. Injuries, or complications•that dinictly caused the death. DO NOT enter terminal events such as cardiac sweat
<br />respiratory arrest or ventrictifar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />deelies ••••• ••••
<br />•••••• • In drialttit'''''' ---
<br />Sequential* iletC•indisittkek •
<br />• etw,,kietlitts to thecoustriiiiiitt'
<br />*)pelltIMOrlia
<br />DUE To,pFt AS A CONSEQU :
<br />bitrantle cell lymphon
<br />: Enterlitisla$RfiTiNU'OrkliS$
<br />(dsfistsbr fillurY that initRted
<br />,ts the events resultingln dealt)
<br />tAtt4..
<br />. • • •
<br />• • " " • • • • •
<br />. • •:•.,
<br />. •• • • •
<br />CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1t:IliART:Iii•OThiffit'SIGNIFICANT CONDITIONS -Conditions contributing to thelleath but. not itisitItlitgke.dwi tin
<br />••
<br />. ....„ , . . .
<br />&O. IFF,EffiKLEi:
<br />Not pse10dnpsstyear 03.10
<br />'tatotist•witi..but 'pregnant Within 42 days of death
<br />Not pregnant, bidlltagnent 4$ days to 1 year before death
<br />.0 <Unknown If gregnafiktiritifin the pest year
<br />22a,DATEOF INJURY(Mo.,:Day, Yr.)
<br />g mime given Ire/PART I.
<br />21a. MANNER OF DEATH "21lie IF TitANSPORTATI
<br />5E1 Natural 0 Homititia Q DrittlinOporator
<br />0 Accident 0 Pending InesettgatiOn'v a PivIrt
<br />0 Suicide 0 Could not be determined Pedestrian
<br />Other (Specify)
<br />22b. TIME OF INJURY
<br />IN
<br />21c. WAS AN A
<br />DYES
<br />14b. RE4TIONSHffiia DtKffitffifir: •
<br />SeetiSe •
<br />169-
<br />may is,
<br />• Nebraetts
<br />1:t.i4;40L
<br />10.10 .
<br />APPROXffillitTEI:
<br />*nest to dath
<br />Minutes
<br />onset to
<br />l'ANeeks
<br />onstavatiat
<br />onset to dasitt
<br />19. WAS toof$04;:iamaiimaft
<br />OR coacimiatitiotriAditit
<br />Yas Ili NO
<br />oatt$Oitu
<br />21d WERE KUT
<br />TO COMPLE
<br />DYES
<br />22c. totke!CE•4101NJURY..At ittirbk ftirm street, fectorY, *Mies btd4ng, constructs
<br />: • ::: :
<br />22e, DESCRIBE HOW INJURY OCCURRED
<br />22t. LOCATION OF INJURV.STREET & NUMBER, APT NO
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 2 2d2
<br />pt. DATE ;wog° (tt,'; 0tY, Yr.)
<br />Mitiii1022
<br />tt lvtio death occurred 511115 time, date and place
<br />inttfititterthOnittissial stated. (Signature Ind Title)
<br />Alexander kananas, MD
<br />crryritiVH: • STATE
<br />23c. TIME OF DEATH
<br />0410 PM
<br />u t
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.1
<br />sik. ton
<br />$ AVAI
<br />DEATH
<br />."••••••••••••'••••...:'••••'!''
<br />, . • •
<br />2,4rK
<br />• '''••••••:4,...
<br />fide. Orithagaliis of examination andior investigation, Sint)/ oliWort fillatfi:ROPPrrettSt '
<br />Bid One, date and placsand due to the cauts(1/ NOR!. iffignettifelfiril$RS
<br />26. DID TOBACCO USE 'CONTRIBUTE TO THE DEATH? 26a. HAEORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES .. NO ' PROBABLY 0 UNKNOWN 0 YES El NO
<br />27. NAME, l'alliKki AD ESS O CERTIFIER (Type or Print
<br />Alexander. Kagenas, MD, 2621 W Faidley Avenue, Grandlsland, Nebraska, 68803
<br />26a. RV:RETRAIN SIGNATURE
<br />266. WAS coesENTORANIVY,
<br />Not Applicable If 26a Is NO y$$
<br />28b. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />May 31, 2022 IN)
<br />44
<br />22d. INJURY AT WORK?
<br />0 YES ONO
<br />
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