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<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHAND-.~ SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE qRIGII't~~~~~~ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, Vrr:ItL STAJ!.lSJ'IC6$~~H 1$
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. // #i. -. ....... .~..-~/.' ~;c....'- I'''''... Yr...........~~.<~..~.-_.~... ';:"':.~ .
<br />DATE OF ISSUANCE . . , -oKI''''- ~'c~ ::~
<br />SEP 11 2006 20'080297 3' ~c, ~~',' TMi~Y$. cc50&R
<br />ASSlS't4NTSTA~. flEGISTitAR
<br />HElf+TH ~"'4~tJH:A1'I;ft~iJCES
<br />
<br />. '.': -. ~,,=.:-..... .: ~.~' ?-:"" .;.~.: :,',?- ..;:::;.~
<br />..~ , ~~'- .....,.\'. - "', "","-
<br />STATE OF NEBRAsKA - DEPARTMENT OF HEALTH AND H~MAN SERVICES FINANCE'ANo.~~~~6" - 2 9 7 0 8
<br />
<br />1. DECED~NT'S'NA~;';:-'~d;;--" C~~~~IFICATE.9F~~~ATH .. ) 2. S~; ~. "";.DA:EOFDEATH (MO.:"Day,yr.) --
<br />
<br />- - .~rvin .---.H~ ----.Me1- - ~Male ......August 31~_06.....-
<br />· "" "","'eo, """"'"' " m,,,,,,,",,,,,,,,"," " ",.C,.. """",' I'" ",",eo "" "- ""'m^, .. ",eo, """ '''. 0,. y, Yr.)
<br />(Yrs ) ~.""'DAYS HOURS r MINS.
<br />St. Libory, Nebraska 89 ~_~~ May 15, 1917. .
<br />
<br />-7.S0Clfti'SECURITYNUMBER - -- - - -__ }_.' Bal:lJ PlOASCpEITO_:ID.EATH -. 0 . . .-...- -'-._
<br />508- 18-5897 m__. LJ Inpalient QIl:IE8; H~UrSingHOme/LTc OHospicsFacllily
<br />6b. FACILIJ)"HAM.E. (IInot IIl.Slltution, give str.eet and numbsr)
<br />Grand Island Veteransm'H~"- ..~_Q.ERI9\Jlp~lleol m .."R"D-!;~d.nt"H"me _"~'.__ ~
<br />
<br />2300 West Capital Avenue 0 CO\ OOther(Spacify)~
<br />
<br />_ B~~:~TO;~~:~H~(ln~:~;:OS=rd~ .~B~O~~'_-=r __ ..ml..6d.COUN;:;~AT~oW1tY .____.~,_
<br />
<br />'.',' ....... ;":." 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br />:;"<2 Nebraska Ha.ll Grand Island
<br />
<br />I~ff "'i."~~;';~" 1~ th St ~ --- ---=r "''' ~'8803 - ';;':::"IT~,":~
<br />
<br />
<br />'.,11 i.. Wa. MARITAL STATUS ATTIME OF DEATH ~ M~rrl.d 0 N~ver MarriectrOb. NAME OF SPOUSE (Fi;~i, Middle, La;i, sumx) If ~'ii~, give maiden name.---- .--
<br />
<br />
<br />~ O"'"~.."'~~"". DW~.._D""'~ O"".~"_"___ . _. Joanne T",,"ons ----c ____
<br />
<br />
<br />:[.'.:~.'.:.'.'.' 11. FATHER'S-NAME (FlrSI; ~iddlo; La.st, SUfflX:J12. MOTHEA'S.NAME (FirS!, Middle, Malden Surnama)
<br />IV"~ Fn.tz W1lh.am Me1nke Martha H. Tuenge
<br />,~6,@ii:, ~-,.",,,._.,,_.,__. '_...'.'_""._. .,_,_. .".__'._..., ,,__,__ ...__ ._...__
<br />.....'.:'..:.,:II.:.,.l.:.....:... 13. EVER IN U.S. ARMED FORCES? Give dala. ot servicaif yes, 114a.INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />,~::f;i (Yes,no,ortnI.f: 4/25/1941 10/21/1945 Joanne Meinke Wife
<br />
<br />i1:j.,,~ 15. ME~HOD OF D;SPOSITION- 16a: EMB.ALMER.S....I..G. N AT~...,.. ~-.. "-... -f 16b.LlC. ENSE N~.. '..,N.. ..~.;6C. DATE'(M.O' Day, 'r';.--;-- 6
<br />iJ[Burial ODonallon_ __ "~__ m~_ /5.:2.~- September 5, 200
<br />
<br />o Creme lion 0 Enlombmenl l6d. CEMETERY, CREMATORY OR THER LOCATION CITY /TOWN STATE
<br />
<br />/
<br />
<br />
<br />~..
<br />
<br />'.
<br />...
<br />\.
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />o Removal U Other (Specify)
<br />
<br />West1awn Memorial Park Cemetery
<br />
<br />NE.
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<br />-~'-,_.,~",._,,- _._._n_. ___. _ __.'_'._ _"._,".
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, Cily orTown, State)
<br />Apfel Funeral Horne, 1123 West Second, Grand Island, NE
<br />
<br />PART I. Enter the QhaI~.Il1~--djseases, injuries, or complicaUons--that cUrect'ly caused-the ~ea1h. DO NOT enter terminal eVenlS .such as cardiac arrasl,
<br />respiratory arrest, or venlrlcular fibrillation wilhout showing Ihe etiology. DO NOT ABBREVIATE. Enter only one caUSe on a line, Add addltJonalllnes if necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />onset 10 death
<br />
<br />IMM~DIAT~ CAUS~ (Final
<br />disease or condition resulting
<br />In dealh)
<br />
<br />~_...Cardil?resp_ira tc:>!Y..1'..a~lur~
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />Sequentially list conditions, If (b)
<br />any,l.odlng to tho couse IIstod -----ouETO, OR AS A CONSEQUENC"E OF: ..
<br />on line a.
<br />Enterthe UNDERLYINQ CAUS~
<br />(dlsaase or Injury that Initiated (c)
<br />1heeventsresultlng Indeeth) -----ouE TO, OR AS A Ci:)NSEOUENCE OF: .
<br />LASr
<br />
<br />-'-~-""_""_".,--,---_.
<br />
<br />I
<br />,7-14 Days_.
<br />
<br />I onset to death
<br />,
<br />I
<br />I
<br />--"~--
<br />
<br />onsat to death
<br />
<br />--.-., -""-"'-"..-. .-,---..
<br />
<br />"~._--
<br />I Onset 10 dealh
<br />I
<br />,
<br />
<br />(d)
<br />---...-.-..-.-..-".-.-.-.-...--...- ...-. ..~...m_. "_.
<br />18. PART If. OTHER SIGNIFICANT CONDITlONS.Condllions contributing 10 the dealh bUI not ro'ulllng in the underlying cause given in PART I. 19..W.. AS MEDICAL EXAMINER
<br />DEmentia, Cachexia, Dyslipidemia, Dysphagia, Chronic A. Fib, OR CORONER CONTACTED?
<br />Adeno CA of Prostate 0 YES ~ NO
<br />-"-'~'-----.. -.. ~,. '-"~-'''-'~,-,," "."--."--.'--
<br />20. IF FEMALE: 21a. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o NOI pregnanl wilhlll pa,t year )OWatural 0 Homlcido 0 Driver/Operator
<br />
<br />o Pregnant al time ot dealh t:I AccidentO Pending Investigallon 0 Passenger
<br />
<br />o Not pregnant, but pregilent wilhin 42 days of death 0 Suicide 0 Could nol be datarmined 0 Pedestrlen 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Nol pregnant, bul pregnanl43 days to , year before dealh 0 Olher (Spoclty) COMPLETE CAUSE OF DEATH?
<br />o Un~nown It pregnant within Ihe past year _ _" _ 0 YES 0 NO
<br />22a.:"DATE OF INJU'RY (Mo., D~y, Yr.) "rMEOF INJUR~2~"PLACE OF INJURY.AI homo, tan", streot, faclory, o!fico building, con.i'-ucllon .lIe',elc.(Specify) .-.~-
<br />
<br />-------.,....~--. I
<br />
<br />o YES
<br />
<br />~NO
<br />
<br />o YES U NO
<br />
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />- --'~-'-......
<br />
<br />22d.INJURY AT WORK?
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<br />22f.lOCATlON OF INJURY. STREET & NUMBER, APT NO.
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<br />CITY/fOWN
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<br />.-"".-. - ~'--_..._-'_..~'-."--
<br />
<br />S'IATE
<br />
<br />ZIP CODE
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<br />23.. DATE OF DEATH (Mo., Day, Yr.)
<br />August 31, 2006
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<br />23b. DATE SIQNED (Mo., Day, Yr.)
<br />e ternber 1 2006
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<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />23c. TIME OF DEATH
<br />8 : 30 P. m
<br />
<br />z>
<br />~~!l;!
<br />H~
<br />15.l1.iI:(~
<br />5~~~
<br />Uw z
<br />1iz;;!
<br />~~o
<br />o.
<br />Uo
<br />
<br />m
<br />
<br />240. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
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<br />24e. On the basis of examination and/or InvBstigatlon, in my opInion death occurred at
<br />the lime, date and place and due 10 Ihe causers) sleted. (Signalure and Title) ...
<br />
<br />THE DEATH?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />- C!..~"~. Q( N().". 0 PR()~ABLY D. UNKNOWN. O_.~~.._~~.__ .. N~ Applicable il 26a is NO.O YES O~
<br />27. NAME, TITLEAND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typa or Print)
<br />M.A. Tanpkins, M.D., Grand Island Veterans Hane, Grand Island, ~'E 68803
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<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR IMo.. Day, Yr.)
<br />
<br />~
<br />
<br />SEP
<br />
<br />7 2006
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