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f) I" n <br />C C") C/) CD <br />N CD —i CD ills <br />c C I� CIO <br />rn C M C:) <br />O Cn <br />o 'TI CD ... <br />C7) -T1 N 3 <br />k <br />1-I. LZ F-A <br />C!'T I--A GO F-A ! Yl <br />1 D � ,x <br />CJ i .4le <br />L� �N' r <br />e �Gi� �� oc�c �' +y� Sever,(37)� Gl�ar(eS Wa.s r*E�rs <br />��.► Ai o v t I G ;K C�'t' Gi( &-, T-5 1 a1"1dl, R A 1 1 Co u,^A% j, Pilo ►�r�.s k --, <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEAL 1 H AND HUMAN SERVICES SYSTEM, VITAL STA77WCS'SECTION; WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE 200213151 <br />Alt <br />ANI: !Cr `COOPER <br />MAY 1 2002 ASSISTANT STATE REGISTRAR <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICSS SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO�tT <br />VITAL STATISTICS - 2 04666 <br />_ CERTIFICATE OF DEATH V <br />I lF- =!IENi <br />—NAME FlRS' MIDDLE LAST SEX �? DAfE OF DEATH ;Alonm Day Vear, <br />Lawrence Fredrick Meyer <br />Male <br />April 11, 2002 <br />4 CITY AND STATE OF BIRTH Ilt-I O USA nano country; <br />Sa AGE - Last 8mhday <br />UNDER I YEAR <br />UNDER I DAY <br />6 DATE OF BIRTH iMpnth. Day Year) <br />Campbell, Nebraska <br />Yr51 83 I <br />November 17, 1918 <br />sb Mo5 DAY$ <br />sc HOURS MINS <br />SOCIA, SECURTIY NUMBER <br />8a PLACE OF DEATH _ <br />508 -07 -0717 <br />HOSPITAL ❑ Inpatra., OTHER ❑ Nursing Home <br />Geddes <br />❑ ER Outpatient FRI Residence <br />81p FACILITY - Name (if nol insolutipn, give street and number) <br />Home: 1408 W. John <br />❑ DOA ❑ Other . Side, IH <br />6c CIT' OWN OR LOCATION OF DEATH <br />Btl INSIDE CITY LIMITS <br />8e COUNTY' CF DEATH <br />Grand Island <br />yes © No ❑ <br />Hall <br />9a 'IEf SIDENCE . STATE 9b COUNTY <br />9c CITY. TOWN OR LOCATION <br />9d STREET AND NUMBER (Including Zp Codei <br />9e INSIDE CITY LIMITS <br />Nebraska Hall <br />Grand Island <br />1408 W. John 68801 <br />Yes 0 No ❑ <br />10 RACE (a g. Whee. Black Amencan Ind— <br />11 ANCESTRY leg. Italian. Mexican, German. etc) <br />12. ❑ MARRIED ® WIDOWED <br />13 NAME OF SPOUSE it( wile give maiden name) <br />etc 1 ISoec' �r1lT <br />� ite <br />Iyl <br />Speot American <br />NEVER DIVORCED <br />MAR I I <br />I (Signature and Tale) ► <br />14a USUAL OCCUPATION /G,ve kind o!work done during most <br />lab KIND OF BUSINESS INDUSTRY <br />15 EDUCATION (Specay only nlgnest grade completed) <br />o! working n!e. even d retired) <br />.b WAS CONSEN GRANTED'r <br />Elementary or Secondary 10 -121 College 1 -4 01 1. <br />Grinder <br />Union Pacific Railroad <br />8 <br />16 FATHER- NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MIDDLE MAIDE14 SURNAME <br />Fred Meyer <br />1 <br />Sophie Nitzel <br />IYaNc J utltAJtU tVtH IN 1,2 U AHMM tU yVMI,tJ� 19a INFUHMANI - NAMt <br />Yes: W <br />II <br />6 -28 -41 8 -3 -45 1 Lonnie Meyer <br />ISO INFORMANT MAILING ADDRESS (STREET OR R F 0 NO. CITY OR TOWN. STATE ZIPI <br />1311 West <br />1st St., Grand Island, NE 68801 <br />20 EMB�SIGNATUR 8 LICENSE NG <br />21a METHOD OF DISPOSITION <br />21b DATE 21< CEMETERY OR CREMn TORY NAME <br />_ <br />26a <br />26b DATE OF INJURY IMO. Day Yr) 26C HOUR OF INJURY <br />QB-al ❑Re—al <br />Aril 18 200 Sunset Memorial Gardens <br />22a FUNERAL HO -NAME <br />_ deceased fell down flight of stair_ <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel - Butler- <br />Geddes <br />❑Cramakon El --o- <br />Hastings, NE. <br />22b FUNERAL HOME ADDRESS <br />ISTREET CR R.F D NO CITY OR TOWN. STATE, ZIP( <br />1123 West <br />Second, Grand Island, NE 68801 <br />23 IMMEDIATE CAUSE <br />(ENTER ONLY ONE CAUSE PER LINE FOR- IN AND Icll Inlenral between ousel aid cea <br />PART <br />' Ia, Trauma <br />to head unknoim <br />UUf. 10. OR AS A CONSEOUENCE OF <br />11 <br />DUE TO OR AS A CONSEQUENCE OF <br />icl <br />Interval between onset a ^d --1" <br />- - ('rte 3 p.'ftiaen pni01 �'1tl peals <br />OTHER SIGNIFICANT CONDITIONS Condmons contributing to the death but not related PART <br />PART <br />III IF FEMALE WAS THERE A 1 24 AUTOPSY <br />25 WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />II <br />IN THE PAST 3 MONTHS7 I <br />EXAMINER OR CORONER' <br />(Ages 10541 Yes No Yes No <br />Yes M No <br />_ <br />26a <br />26b DATE OF INJURY IMO. Day Yr) 26C HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident ❑ Undetermined <br />pr 11, 2002 App 2:30 D <br />_ deceased fell down flight of stair_ <br />❑ SUIC do ❑ Pen tlmq <br />26e INJURY AT WORK <br />261 PLLACE OF INJURY - At home, farm street factory <br />oHlce budding. etc /Spec/ly) <br />26g LOCATION STREET OR R F D NO CITY OR TOWN STATE <br />❑ HQIniGde Investigation <br />Yes ❑ NO ® <br />home <br />1408 W John. Grand Island, NE___ <br />F <br />27a DATE OF DEATH (MO Day Yc) <br />28a DATE SIG ED IMO. Day y,) 28b TIME Of DEATH <br />$ i <br />W- ;approx 2:30 pp <br />& a r27b DATE SIGNED /MO Day Yrl 27c TIME OF DEATH <br />28c PRONOUNCED DE Me Day. Vrl PRONOUNCED DEAD /Houa <br />jQO M <br />5 4 J I <br />sa=� <br />° g o <br />April 1, 002 :20 m - M _ <br />a 270 tO nT e Dent of my knowledge death Occurred at the time. date and plate and due to the <br />28e. On the basis of xam,nal— and r vesll 1, ed at <br />causefsi stated <br />, the time, dale a place and due <br />I (Signature and Tale) ► <br />ISignature and Tulel <br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH'+ <br />30a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED' <br />.b WAS CONSEN GRANTED'r <br />I ❑ YES n NO ❑ UNKNOWN <br />l_ <br />❑ YES NG <br />❑ YES IN NO <br />I — <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY, I type or Pnni' <br />S -t Dale Hilderbrand, GIPD, 131 S Locust, Grand Island, NE 68801 <br />32a REGISTRAR 321 DATE FILED BY REGISTRAR !Mo. Day YU <br />(4Id 0110l, _ APR 2 3 2002 - -- - <br />I id 6�-- <br />f/ <br />