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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE TRUE COPY OF THE ORIGINAL REC¢N FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERV ICES SYSTEM, VITAL STATIsilCS.SECT-tON,- zWIIICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE L
<br />2 8 JAN �)) = TA
<br />JA ft -EYS. COOPER
<br />2 0 0 5 4 2 2 9 5 ASSISTANT S'TATL-REGISTFFAR
<br />LINCOLN, NEBRASKA HEALTF! AND HUMAN S_ ERVICES
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />! CERTIFICATE OF DEATH - �4
<br />- -. -
<br />i 1. DECEDENT'S•NAME (Fi(st, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo,. Day. Yr.)
<br />Gertrude Meyer Female January 14, 2005
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (MO., bay, Yr.)
<br />Yrs. MOS. DAYS HOURS MINS.
<br />St. Michael, Nebraska ( ) 86 October 2, 1918
<br />7. SOCIAL SFCURI IY NUMBER Ba, PLACE OF DEATH
<br />505 -74 -6068 HOSPITAL: 51 Inpatient OTHER: U Nursing Home /LTC U Hospice Facility
<br />-- - .._... flit FAr:1LI I:.Y- NA.ME... (t1 na1 insliiu!ipn, g!sc :Sr_ -vt and twmhei�... _. -- - -- - -. - -. - -- - ,..._..._ ... .. ._ ._. _. -. ..
<br />QER /Outpatlenl ❑ Decedent's Home-
<br />Saint
<br />T
<br />Francis Medical Center
<br />❑ D3A U Other (Specify)
<br />Se. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />- -- - _.
<br />98. RESIDENCE -STATE 9b.000NTY 9CCITYORTOWN
<br />Nebraska Hall Grand Island
<br />9d. STREET AND NUMBER 9e. APT. NU 9f. ZIP CODE 9g INSIDE CITY LIMITS
<br />1905 Prospect St. 68803 m YES Q NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married lob. NAME OF SPOUSE (First, Middle, Last, Suffix) It wife, give maiden name.
<br />Cl Married, but separated 99 Widowed ❑ Divorced U Unknown
<br />y 11. FATTIER 5 -NAME (First, Middle. Last, Suffix) 12 MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />I�. Charles Schultz Martha Schlund
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if yes 14a.INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yes, no, or unk.) No Jolene Nelson daughter
<br />Qil Burial ❑ Donation � � a R- SIGNAT�RE �� 16b, LICENSE N0, 16c. DATE (MO., Day, Yr. )
<br />15.M Burial OF DISPOSITION 16 BALMF� - � _ - I 1328 January 18, 2005
<br />❑Cremation C3 Entombment 16d.CEMETER CREMATORYOROTHE/iLOCATION CITY /TOWN STATE
<br />URemoval U other (Specify) Mt. Pleasant Cemetery Cairo Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust St., Grand Island, Nebraska F880J.
<br />m it i
<br />18. PART I. Enter the Chain 9f events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add additional Imes if necessary. I
<br />IMMEDIATE CAUSE: ousel to death
<br />❑ YES I NO U PROBABLY U UNKNOWN YES NO L Not Applicable If 26a is NO
<br />LE ❑ YE NO
<br />` 27. NAMF, TITAND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />David Colan, M.D_,'729 N. Custer Ave., Grand Island, Nebraska 68803
<br />�- 28a, REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR. (Mo., Day, Yr.)
<br />JAN 7, 4 20005
<br />IMMEDIATE CAUSE (Final (a)
<br />23a. DATE OF DEATH (Mo., Day, Yr.) z a 24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />.,_�`,�'
<br />disease or condition resulting DUE TO, ORASA CONSEQUENCE OF;
<br />onset 10 death
<br />January 14, 2005 %a
<br />in death)
<br />Asa
<br />Sequentially list conditions, if (b) �%'✓ ui�j(
<br />_
<br />24d. TIME PRONOUNCED DEAD
<br />S /�/j' /J
<br />any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF;
<br />)� 9 -US 0105 a, m E yaz
<br />m
<br />online a.
<br />onset to death
<br />Enter the UNDERLYING CAUSE
<br />c
<br />F
<br />and d to the cauae(s) Staled. (Sin�tqre and Title) ♦ �' m
<br />Z �he lime, date and place and due to the cause(s) stated. (Signature and Title)
<br />(disease or injury that lnllisted (c)
<br />Q
<br />o
<br />~Uri
<br />the events resulting In death) -- _-
<br />LAST DUE T0, OR AS A CONSEQUENCE OF:
<br />- --
<br />-
<br />onset to death
<br />25. DID
<br />(d)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />I
<br />I
<br />18. PART HER SIGNIFICANT COND11IONS•Condlllons contributing to the death but not resulting in the underlying cause given in PART 1.
<br />i9. WAS AEDICAL EXAMINER
<br />f11.'01
<br />f-4 ( L a4- pr�
<br />a YOSONERU❑CONOACTED?
<br />w
<br />2q, IF FEMALE :
<br />21a.MANNEROFDEATH
<br />21 b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />r
<br />ANOI pregnant within past year
<br />atural U Homicide
<br />Cl Driver /Operator
<br />�
<br />❑Pregnant at time of death
<br />❑Accident❑ Pending Investigation
<br />Passenger
<br />❑Passen
<br />❑YES ENO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />U Suicide ❑Could not be determined
<br />❑ Pedestrian
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />❑ Not pregnant, but 43 days to 1 before death
<br />❑ Other (Specify)
<br />pregnant year
<br />COMPLETE CAUSE OF DEATH?
<br />❑ Unknown If pregnant wit hin the past year
<br />- -__ .-
<br />❑ YES ❑ NO
<br />72a DATE OF INJURY Mo., Day, Yr.)
<br />a2h TIME OF INJURY
<br />22c PLACE OF IiJJURY -At home, faun,
<br />slreel, factory, office building, consiluction
<br />site, etc. (Specify)
<br />y
<br />AllOn
<br />22d.INJURYA'TWORK7
<br />- .......
<br />,. -.
<br />.......- ...
<br />❑ YES U NO
<br />F212e.SCRIBEHOWINJURY000URRED
<br />22f.I.00ATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN
<br />STATE ZIP CODE
<br />❑ YES I NO U PROBABLY U UNKNOWN YES NO L Not Applicable If 26a is NO
<br />LE ❑ YE NO
<br />` 27. NAMF, TITAND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />David Colan, M.D_,'729 N. Custer Ave., Grand Island, Nebraska 68803
<br />�- 28a, REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR. (Mo., Day, Yr.)
<br />JAN 7, 4 20005
<br />23a. DATE OF DEATH (Mo., Day, Yr.) z a 24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />95
<br />January 14, 2005 %a
<br />m
<br />Asa
<br />.._.. - -_.... - -.
<br />23b. DATE SIGNED (Mo. ay,Yr.) 23c.TIMEOFDEATH �'_ 24c. PRONOUNCED DEAD (Mo,, Day. Yr,)
<br />_
<br />24d. TIME PRONOUNCED DEAD
<br />E 1
<br />)� 9 -US 0105 a, m E yaz
<br />m
<br />23d.To the best of my knowledge, death occurred at the time, data and place 0 Lu = 24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />c
<br />F
<br />and d to the cauae(s) Staled. (Sin�tqre and Title) ♦ �' m
<br />Z �he lime, date and place and due to the cause(s) stated. (Signature and Title)
<br />Q
<br />o
<br />~Uri
<br />25. DID
<br />TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />I 26b WAS CONSENT GRANTED?
<br />❑ YES I NO U PROBABLY U UNKNOWN YES NO L Not Applicable If 26a is NO
<br />LE ❑ YE NO
<br />` 27. NAMF, TITAND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />David Colan, M.D_,'729 N. Custer Ave., Grand Island, Nebraska 68803
<br />�- 28a, REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR. (Mo., Day, Yr.)
<br />JAN 7, 4 20005
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