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<br />JUN 1 4 2006
<br />LINCOLN, NEBRASKA
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<br />STATE OF NEBRASKA __
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALT#~,(/jj,HiJt:ij,jf~VICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGI. REcoiEQ,iili RLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA7JST1C$ Sa:'i'ioNgWHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. fl '",:!' -' '" 'J,
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<br />4a1r!~~l
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<br />, ASSI~.TA~T $TA.r~"'E.GISTRAR
<br />HEALT#A~ HUMANSEFlVtCES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE"ANDSUPPORT "
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<br />2006060q5
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<br />DATE OF ISSUANCE
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<br /> CERTIFICATE OF DEATH -- , rl1 cc: "): h, Ii; ? 1,
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<br />N 1. D.C.D.NT'S.NAM. (Firsl, Middl., Lasl, Sullix) 2, SEX .., .~- '""... -...
<br />\ 3, DAT. OF DEATH (Mo., Day, Yr,)
<br /> Frederick Ernest Meyer Male June 9, 2006
<br />\ I 4, CITY AND STATE OR T.RRITORY, OR FOREIGN COUNTRY OF BIRTH Sa, AG..Last Blrlhday 5b, UNDER 1 Y.AR 5c, UNDER 1 DAY 6, DATE OF BIRTH (Mo" Day, Yr,)
<br /> (Yrs,) MOS, I DAYS HOURS I MtNS,
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<br /> Grand Island, Nebraska 79 December 2, 1926
<br /> 7, SOCIAL SEOURITY NUMBER 8a, PLACE OF DEATH
<br /> 506~22-4077 1:JQill'.JM1. : o Inpatl.nl QJJ1J;B: o Nurnlng Hom./L TO o Ho'plc. Facility
<br /> Bb. FAOILlTY.NAME (If not Inslitutlon, glv. str..t and numb.r) U ER/Outpatl.nl 00 D.c.d.nl's Horn.
<br />- -~ . --:0: -~ ';-,: ;-".:':;' ~~.,:' ~." -;;:-~;.,7"""":;:~,.--::-""W""':J" J>'.
<br /> , ~ :,_.n ;.,-'if'-':''':;;-.~''' ~ ';"':,:,;...", "-::"7f,., r''''''''':
<br /> uJ .. ....."~:..':~~..,,""'"- "'~, , ... Uln\
<br /> '" 431 Stagecoach Road I.,:.J umer(~ptlalJ'1 .. . ~. '-
<br /> 15 __0..-- _.~.,-_._-". ---
<br /> ...J 8c, CITY ORTOWN OF DEATH (Includ. Zip Ood.) 8d, COUNTY OF DEATH
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<br /> '" Grand Island 68801 Hall
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<br /> ;z ga, RESIDENCE.STATE i9b' COUNTY I 9C, CITY OR TOWN
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<br /> i Nebraska Hall Grand Island
<br /> " 9d, STREET AND NUMBER Iga, APT, NO Igl. ZIP CODE -1 gg, INSIDE CITY LIMITS
<br /> :E 431 Stagecoach Road 68801 IJa YES 0 NO
<br /> ~ lOa, MARITAL STATUS AT TIME OF DEATH bd Marriad LJ Nev.r Married 10~, NAME OF SPOUSE (Firs!. Mlddl., Lasl, Sulllx) If wll., glv. mald.n name,
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<br /> C- O Marn.d, but separaled 0 Wldow.d o Divorced 0 Unknown
<br /> E Leah Geil
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<br /> .. 11, FATHER'S.NAME (Flrsl, Middle, Last. SUlJlx) \12, MOTHER'S'NAME (Firsl, Middle, Malden Surname)
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<br /> t2 Robert Auqust Mever Catherine Hackman ---
<br /> 13, EVER IN u.S, ARMED FORCES? Give dat.s 01 S.rvic.llyes'j 14a, INFORMANT.NAM. 14b, RELATIONSHIP TO DEOEDENT
<br /> (Y.s, no, orunk,) Yes:Y;;efl9:E - 9/S1% Leah Meyer Wife
<br /> 15, METHOD OF DISPOSITION 16a, EMBALMER-SIGNATURE I 16b, L10ENSE NO, 16c, DATE (Mo" Day, Yr. )
<br /> :l Burial o Donallon Not Embalmed June 9, 2006
<br /> ll\I Cr.ma~on o Entombment lSd, CEMOTERY, CR.MATORY OR OTHER LOOATION CITY /TOWN STATE
<br /> o Removal U Other (Speclly)
<br /> Central Nebraska CrematlDn Service Gibbon Nebraska
<br /> 17a, FUNERAL HOM. NAME AND MAILING ADDRESS (Slree!. City orTown, Stale~ T 7b, Zip Ood.
<br /> All Faiths Funeral Home, 2929 S, Locust Street, Grand Island, ebraska 68801
<br /> CAUSE OF DEATH (See instructions and examples)
<br /> t8, PART I. Enler Ih. chain 01 ev.nlsudi.eas.s, InJuries, or compllcallons--Ihal dlreclly caus.d the d.alh, DO NOT .nl.r lermlnal.venls such as cardiac arr.sl, APPHOXIMATE INTERVAL
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<br /> respiratory arr.sl, orv.nlrlcular librillallon wilhoul.howlng the .Uology, DO NOT ABBREVIAT., Enl.ronly on. caUsa on a Iln.,Add addllionalllnes If n.cessary, I
<br /> IMMWIATE CAUSE: I ons.llo d.alh
<br /> C~-<:>:.."-V---c ,G..") ,~ ~ : C,~~-?,
<br /> IMMEDIATECAUSE(Fl1al (a) !-.~ --J-o--rz./ ---v-?
<br /> dls.... or condnlonruultlng DUE TO, OR AS A CONSEQUENCE QF: f' I onset 10 dealh
<br /> I1de.lh) I
<br /> (b) I
<br /> s.quentl.lly lI.t condition., It I
<br /> .ny, I.adlng 10 Ih. cau..lIsl.d DU. TO, OR AS A CONSEQUENCE OF: I ons.llo dealh
<br /> on IIn. a. I
<br /> Enter 1M UNDERLYING CAUSE I
<br /> (dl..... or Injury thallnlllat.d (c)
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<br /> Ihe .v.nla r..ulllng In d.alh) DUE TO, ORAS A CONSEQUENOE OF: I on..t 10 death
<br /> lAST I
<br /> (d) I
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<br /> IB, PART II. OTHER SIGNIFICANT CONDITIONS. Condition. conlribUllng to Ih. d.ath but not r.sulllng In the underlying caus. glv.n In PART I. 19, WAS MEDICAL.XAMINER
<br /> OR CORONER CONTACTED?
<br /> o Y.S );:(NO
<br /> '" 20, IF FEMALE: 21a, MANNER OF DEATH 21b, IFTRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br /> W
<br /> u: U Nol pr.gnant within pa'l year )tNatura! U Homicide U D~v.r/Op.talor
<br /> ~ U YES XNO
<br /> uJ o Pregnanl at lime 01 d.alh o Accld.nto P.ndlng Inv.s~gallon o Passenger
<br /> U o P.de.lrlan
<br /> k U Nol pr.gnanl, bul pregnant within 42 days 01 de.1h o Suicld. U could nol b. dalermln.d 21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> " o Not p..gnant, bul pregnanl43 days 10 1 yearb.'or. dealh o Olher (Sp.clly) COMPLETE OAUSE OF DEATH?
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<br /> '" Q-Utll<I1<lW/l iI proljfl"'" wltAln Iha pa.1 y~..--- O_Y_ES UNQ
<br /> ... --- --. ". ---- --.. - .- ,- . . - ._.
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<br /> 0 22a, DATE OF INJURY (MO" Day, Yr,) 122b' TIME OF INJUR: 1 22c, PLACE OF tNJURY.Athom., farm, str..t, faclory, offloe building, conetrucUon slto, ole. (SpeCify)
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<br /> t2 22d.INJURY AT WORK? I' 22., D.SCRIB. HOW INJURY OOCURRED
<br /> U YES o NO
<br /> 221, LOCATION OF INJURY - STREOT & NUMBER, APT. NO. CITYITOWN STAT. ZIP COD.
<br /> 23a, DATE OF DEATH (MO" Day, Yr,) z>-- 24a, DATE SIGNED IMo" Day, Yr,) 24b. TIME OF DEATH
<br /> >-~ June 9, 2006 ~~~ m
<br /> i!;! 23b, DA{ S;~ED)~~, t' Yr,) I 23c, TIME OF DEATH iCi5~ 24c, PRONOUNCED DEAO (Mo" Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br /> 'liig! ]!~~
<br /> 'a.:I::J 04 : 0 Sa. m Q.D.. < ~ m
<br /> Eo..Z ~~~i5
<br /> 8 g>o ..,,, ,"",'" ""~~" 00.. .=,,~ ,,~ "~. ""~" .". ouJZ 24e, On Ihe basis 01 .xamlnallon and/orlnve.t1gallon, In my opinion dealh occurred al
<br /> 1;'g and due 10 the cause ) slated, (Slgnalur. and TltI.) T "z::> tll.tlm., dal. and plac. and due to lhe cau,.(s)'lated, (Slgnalure and TltI.) T
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<br />:J 25,DIDTOIlACOO USE CONTRlBUT:~B~HE DEATH1 128a, HAS ORGAN OR TISSUE ~ONATION BEEN CONSIDERED? !26b. WAS CONSENT GRANTED?
<br />::;> DYES 0 ~RO ABLY 0 UNKNOWN 0 YES )sI:NO Not Applicable If 26a I. NO U YES UNO
<br />27, NAME, TITLE ANDA RESSOF CERTIFIER (PHYSICIAN, OORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type orPnnl)
<br /> Gordon Hrnicek, M.D. , 729 N. Custer Ave. , Grand Island, NE 68803
<br /> 28a, REGISTRAR'S SIGNATUR. ~4J. I~/1 28b, DATE FILED BY REGISTRAR (Mo., Day, Yr,) 1
<br /> p JUN 1 3 2006
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