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.200305110 WHEN THIS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD Ol FIL 1TH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA T/STW9 WTWN, WNCF€IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCEQ' MAY 7 22��_'G`Q_OP12 LINCOLN, NEHRASl01I ASSIi$fiiiT G /St(#A�_ HEALTH AND HIIVA#4q"V YSTEA¢- STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERWES_ti SUFI RT VITAL STATISTICS = 1 04746 CERTIFICATE OF DEATH - _ 'I. DECEDENT. NAME FIRST MIDDLE LAST 12 SEX 3. DATE OF DEATH IMonm Day Yearl Kimberly Jo Meier Female= April 13, 2001 0. CITY AND STATE OF BIRTH lUnol in USA.. name counfryl 5a. AGE Last hday I UNDER 1 YEAR UNDER t DAV 6, DATE OF BIRTH IMontA Day Year) Grand Island, Nebraska I- (Y's 43 5b MOS DAYS 5c. HOURS MIN$ March 3, 1958 7 SOCIAL SECURTIY NUMBER Be PLACE OF DEATH 505 -82 -5804 HOSPITAL ❑ mpanent OTHER ❑ Nursing Home ❑ ER Outpatient ® Residence 8b FACILITY - Name /tl not institution. give street and number/ Home: 7692 S. Gunbarrel Road ❑ DOA ❑ Other ISpecdv, Be CITY TOWN OR LOCATION OF DEATH ad INSIDE CITY LIMITS Be COUNTY OF DEATH Doniphan Yes ❑ Np Hall 9a RESIDENCE - STATE 9b COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER (Including Lb Code) 6883 9e INSIDE CITY LIMITS Nebraska Hall Doniphan 7692 S. Gunbarrel Rd. Yee ❑ No 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY Wig Italian, Mexican, German. etc) 12. ❑ MARRIED ® WIDOWED 13. NAME OF SPOUSE IN wrle. gne maiden name) etc .I lSoecifyl White (Specify) American NEVER DIVORCED MARRIED Mitchell D. Meier 14a USUAL OCCUPATION (Give ktridot work done during most " b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) of working Irl9, even it retired! LPN /Scrub Tech Nursing /Surgery Center Elemenlar or Secondary 10 -121 Collage ?1 .4 or 5.1 2 4 16. FATHER -NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME Daryl White F Joyce Arlene Sundstrom 1B. WAS DECEASED EVER IN U.S. ARMED FORCES' 19a INFORMANT -NAME (Yes o or unt.) N yes. give war and dates of servicesl No Daryl White 19b INFORMANT MAILING ADDRESS ,STREET OR R.F.0 NO. CITY OR TOWN STATE ZIP) .--.2515 W. Oklahoma Ave., Grand Island, NE. 68801 EMBA ER - SIGNATURE 8 LICENSE NO 3+ 21 a METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME Ar (% Burial F] Burial April 25, 200 Central Nebraska Crematic FUNERAL HIbME - NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler- Geddes ® Cremation ❑ Donalun Gibbon, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP) 1123 West Second, Grand Island, NE. 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR let. Ibl. AND (0 Interval between onset and oeam PART I I SP014TANEOUS CARDIAC ARRYTHMIA UNKNOlYT14 ,al DUE TO, OR AS A CONSEQUENCE OF 1 Interval between onset and death I Ib1 DUE TO. OR AS A CONSEQUENCE OF Interval between onset and dealt, Icl i OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART 111 IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS' EXAMINER OR CORONER' II )Ages 10 -54) Yes No v yes No Yes No 26a 25b DATE OF INJURY (Mo.. Day. Yr) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Arc. dent Undetermined M Suicide F-1 Pendinq 26e INJURY AT WORK PLACE OF INJURY - At home. term . street factory 26g. LOCATION STREET OR R D NO CITY OR TOWN STATE Homiutle hvesogalion ❑❑ Yes No ❑ 1261 office but ng. etc lSpecltyl 27a DATE OF DEATH (Mo Day vr) 28a DATE SIGNED /Mo Day Yr I 28b TIME OF DEATH $ z a } M 95 DATE SIGNED lMo. Day. Yr) 27c TIME OF DEATH 28c P ONOUN ED DEAD lMo.. Day. Yr.l 28d. PRONOUNCED DEAD /HOUrI o ¢ i o gRd M �� ° M 27d To the best of my knowledge death occurred at the time, date and place and due to the 2Be On the basis of examin2lipn and or invest,gahon, to my opinion death occurred al cause,,, slated. the time date and place and due to the causelsl stated. I. ,alone and Title) ► (Signature and Title 29 DID TOBACCO USE CONTRIBUTE TO THE DEATHS 30.a HAS ORGAN OR TISSUE DONATION CONSIDERED° 30A C NS NT GRANTED° 1BE�EN wE5 NO ❑ UNKNOWN ❑ YES VI NO ❑ YES V NO t� 3! NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, 'Type or P-1i 1 32. REGISTRAR 32b DATE FILED By REGI RAR (Mo.. Day Yr.) AkAj I MAY 0 4 2001 [II fl Y