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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 A TRUE COPY OF THE ORIGINAL RECOBQ ON -FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS -Mr- TION;: ]A!#f/CIlIS _
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE _
<br />MAR 2 200 TtANLF-YS tOOP_ER
<br />ASSISTANT-STATE REGISTRAk
<br />LINCOLN, NEBRASKA HEALTH AND HtJ1biA_ N SERVICES
<br />200503174
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH 05 029,
<br />........ ._.... ..._.
<br />1. DECEDENT'S -NAME (First, Middle, Last,
<br />Robert Lee Meahan
<br />4. CITY AND STATE OR TERRITORY, OR
<br />FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska.
<br />7. SOCIAL SECURITY NUMBER
<br />505 -42- 3855
<br />8b. FACILITY-NAME (If not Instllutlon, give street and number)
<br />St. Francis Skilled Care Center
<br />Sufflx) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Male March 4, 2005
<br />Be. AGE -Lass Birthday 5b. UNDER 1 YEAR 5c, UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.) 66 MOS. DAYS HOURS I MINS. -ril 13, - 1938
<br />Ba. PLACE OF DEATH
<br />HOSPITAL: U Inpatient 4DdE8: XJ Nursing Home /LTC U Hospice Facility
<br />❑ ER /Outpatient ❑ Decedent's Home
<br />L1 DOA U Other (Speclfy)-
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) Sd, COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE•STATE 9b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />_....- - -. . .. J
<br />9d. STREET AND NUMBER 9e. APT. NO 9f. ZIP CODE
<br />209 W. 8th _ 68801
<br />10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />I10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />❑ Married, but separated Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last Suffix)
<br />23a. DATE OF DEATH (Mo., bay, Yr.)
<br />12 MOTHER'S NAME (First
<br />William Meaban
<br />--
<br />24a.DAT E SIGNED (Mo., Day, Yr.)
<br />Beth
<br />13, EVER IN U.S, ARMED FORCES? Give dates of service if yes.
<br />14a.INFORMANT -NAME
<br />(Yes,no,orunk.) Yes: 9/23/1958 9/22/
<br />- - - -- - - - - --
<br />961
<br />Kevin Meahan
<br />- --
<br />15. METHOD OF DISPOSITION
<br />15a. EMBALMER- SIGNATURE
<br />23c,TIME OF DEATH
<br />16b. LICENSE NO
<br />Burial ❑ Donation
<br />..>
<br /># 47A"
<br />❑ Cremation ❑ Entombment
<br />16d. CEMETERY, gEMATORY OR OTHER LOCATION
<br />CITY / TOWN
<br />9g. INSIDE CITY LIMITS
<br />N YES ❑ NO
<br />Middle Maiden Surname)
<br />Irene Marvel
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (Mo.. Day, Yr.)
<br />March_ 9, 2005
<br />STATE
<br />LJRemoval U Other (Specify) Grand Island Cemetery, Grand Island,
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home 1123 W. 2nd, Grand Island, NE.
<br />18. PART I. Enter the chain of events.-diseases, injuries, or compllcations••ihat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrlllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />In death)
<br />Sequentlally Ilet conditions, If
<br />any, leading to the cause listed
<br />on line a.
<br />Enterthe UNDERLYING CAUSE
<br />(disease or Injury that initiated
<br />the events resulting in death)
<br />LAST
<br />F
<br />(a)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(b)�..c._i (..�C."!�'- C..., -�, r-f rte- -•cam.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(c)
<br />DUE T0, OR AS A CONSEQUENCE OF:
<br />(d) ....__....
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />C1.•1 G:� a.�_�- ` C. LD l osi1 V_.)
<br />20. IFF�h1ALE, 21a.MAN1�&R"OFDEATH 21b.IFTRANS0 A ONR
<br />l -i'T of pregnant within past year ;atural ❑ Homicide Cl Driver /Operator
<br />U Pregnant at time of death ❑ AccldentU Pending Investigallon ❑ Passenger
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />I
<br />I
<br />onset to death
<br />I
<br />I onset to death
<br />i
<br />1 onset to death
<br />I
<br />onset to death
<br />I
<br />I
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />_ ❑ YES 2-N0
<br />IURY 21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 93'50
<br />U Not pregrianl, but pregnant ❑ wllhln 42 days of death Suicide ❑ Could not be determined LJ Podestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death U Other (Specify) COMPLETE CAUSEOFDE9TH?
<br />❑ Unknown If pregnant within the past year ❑ YES l- al'_flr0�
<br />�4N2iJAA' �1dv:; eay,-W.) . TtNlEtvr -d dHT- -1 zZcPLACIF OF TNJURY•At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />m
<br />22d.INJURYATWORK? 220, DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. N0, CITY/TOWN STATE ZIPCODE
<br />23a. DATE OF DEATH (Mo., bay, Yr.)
<br />....'
<br />_
<br />�
<br />--
<br />24a.DAT E SIGNED (Mo., Day, Yr.)
<br />24b.TIME OF DEATH
<br />�s
<br />y
<br />., ,J 41 C..�
<br />ggz
<br />m
<br />U
<br />y
<br />236. DATE SIGNED (M0 , Day, Yr.)
<br />23c,TIME OF DEATH
<br />_ cc
<br />9 y
<br />_
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />March 10, 20pY�
<br />'l> Lyy m
<br />�W..%
<br />}
<br />a4a �
<br />m
<br />00
<br />o e
<br />23d.To the b�sl of m);know dg da occur
<br />1.
<br />at the tim , date and place
<br />02 0
<br />a ?
<br />24e. On the basis of examination and /or Investigation, In my opinion death occurred at
<br />`1
<br />and N'e! fhAdau a led.
<br />and Title)
<br />0 U
<br />the time, date and place and due to the cause(e) stated. (Signature and Title)
<br />La
<br />("
<br />0 0
<br />25. OD�IDT
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />261b. WAS CONSENT GRANTED?
<br />TO/OBACCOUSECONTRISUTETOTHEbEA
<br />L:f'YES! U NO LA PROBABLY ❑ UNKNOWN
<br />❑ YES
<br />Id'NO
<br />Not Applicable if 26a Is NO U YES 'NO �'"
<br />L�
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Kenneth Vettel M.D.
<br />2116 W. Faidl.ey
<br />Ave.
<br />Grand Island, NE. 68803
<br />28a. REGISTRAR'S SIGNA7URE
<br />- , �
<br />26b. DATE FILED BY REGISTRAR (6 2005
<br />
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