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<br />WHEN n;s COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL THAND Hi!l!!McSERVltJElJ., .
<br />fYSTEM, "CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REtili1fD.:(J#FI~TH .
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM. VITAL STAT/Srfi,~p!C'IMN.~'W!JLCfft:J}J
<br />
<br />
<br />;i;:;;TORYFORWTALRECORDL ~~
<br />LiNCOLN, NEBRASKA 20080 9 i 12 HEALTH A~~S:r;:';~~;~~~1
<br />
<br />
<br />- -'...
<br />. ~
<br />. .-
<br />-
<br />
<br />STATE OF NEBRASKA- DEPARTMENT OF HEAL rn AND HUMAN SERVICES F'INAl'Itl'XND SUPPORT
<br />VITAL STATISTICS 02
<br />CERTIFICA TE OF DEATH
<br />
<br />05092
<br />
<br />, DECCD[NT:NA;'U:--- --_.-~---_.-
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />:; SEX
<br />
<br />:3. DATE OF DEAn" !Moml) 0<.1'1. Yearl
<br />
<br />Dennis
<br />
<br />LeVerne
<br />
<br />Meismer
<br />
<br />Male
<br />
<br />April 27, 2002
<br />6. DATE OF BlI1TH IMonth, D('lv Y~CJ;t~~"~-,._,_.
<br />
<br />4. CITy ANOSj"ATE or BIRTH IIf not in U SA name COIJntrVJ
<br />
<br />s,i AGF - La!il SIrll1dCl.Y
<br />IY,,' 90
<br />
<br />UNDER 1 VE::AR
<br />'b MOS DAYS
<br />
<br />UNDER 1 DAY
<br />5c HOURS MINS
<br />
<br />April 05,1912
<br />
<br />Hamilton County Nebraska
<br />TSOCiAi"SECURTIY NUMBER
<br />
<br />507-48-8716
<br />
<br />Sa PLACE OF O~ATH
<br />HOSPITAL
<br />
<br />D InDalienl OTHER I!J Nursing HUnli'!
<br />D fR QUlpatienl D AeslClcr"IGC
<br />D lY.)A D Olhci' iSO~?I:'lv
<br />
<br />Bb. F-A(~ILlfY _ Na;Y;c'--J.'~-'~---~
<br />
<br />(If nnf institution, give !i/r~f~rio number)
<br />
<br />~everly Healthcare
<br />
<br />ec. CITY To"WN OR LQCA TION Of:" DEATH
<br />
<br />at Lakeview
<br />
<br />14,a, USUAL OCCUPATION (Give kind of work dOfle tjl,Inl'lg mo.t;r
<br />of worlong life. even if ferired)
<br />Retired Farmer
<br />
<br />"0
<br />
<br />
<br />Yes KJ No
<br />
<br />Od INSIDE CITY L1MllS~'~
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />10, RACE - (e,g.. Whil~. BlacL.., American Indian
<br />file,) tSoec,ly)
<br />White
<br />
<br />
<br />11. ANCEST Av la,g llalian. ME!J(lcan, Oerm.al'1. elc::l
<br />rSpeclly)
<br />American
<br />
<br />Yes ~ No D
<br />13 NAME OF SPOuSi:: 111 wde. give maidi;!n nam~)
<br />
<br />9a' RF.SIDE;NCE - STATE
<br />
<br />COUNTY
<br />
<br />9d STREET AND NUM6~R (Jnc:ludlfl() ZIp CIXI~!
<br />
<br />ge IN SlOE CITY LIMIT S
<br />
<br />Phyllis Zehr
<br />
<br />MIDDLE
<br />
<br />Agriculture
<br />LAST
<br />
<br />15, EDuCATION lSpec1fy only hlghes1graae complelecJ)
<br />Elemnry or Secondary 10.12) College fl.!! or ~1'1
<br />
<br />16 FAfHER - NAME
<br />
<br />FIRS1
<br />
<br />
<br />17 MOTHER
<br />
<br />MIDOI,F
<br />
<br />MAIDEN SURNAMF
<br />
<br />Adam
<br />
<br />Adeline
<br />
<br />v
<br />
<br />Vetter
<br />
<br />I"il"W^S OFCEASEO EVER IN u,S ARMED rOAC[S?~'.
<br />(Yes ....0 or l.mlr;,j !II YP.!; give war a("l(/ d.lIe~ 01 ~e'Vlcas)
<br />No
<br />
<br />NAME
<br />
<br />, 90 INFORMANT
<br />
<br />MAILING ADDRE:SS
<br />
<br />Phyllis Meismer
<br />ISTREET OR R.F 0 NO. CITY OR TOWN SlATE. ZIPI
<br />
<br />2412 Stagecoach Road, Grand Island, Nebraska 68801
<br />
<br />20 EM: MER:~GNAT~L1(E;",~ 1129 21a...ETHODOFDlsPOsmON
<br />
<br />J\t, fT\ LV ~ auri~l D Rt:!l'nOval
<br />22a, ~uNERAL HOME - NAME
<br />
<br />21b. DATE
<br />
<br />21c, CEMETERY OR CREMATORY NAME
<br />
<br />05/01/2002
<br />
<br />Aurora Cemetery
<br />
<br />Higby-McQuiston Mortuary
<br />
<br />D cremalionDDon.allC){l
<br />
<br />2'0. C[METERY OR CREMATORY LOCATION
<br />
<br />Aurora, Nebraska
<br />
<br />CITy OR TOWN
<br />
<br />."-.'SiAi[--
<br />
<br />220. fuNERAl. HOME ADDRESS
<br />
<br />[STREE:.T OR R.F.D, NO CI1V OR TOWN. STATE. ZIPl
<br />
<br />I P.O. Box 204 Aurora, NE, 68818-0204
<br />'-----
<br />I 23. IMM[QIATE CAuSE IENTER ONLY ONE CAUSF PFR LINE FOR '.1101. AND lell
<br />PART
<br />: I fal MYOCARDIAL INFARCTION
<br />'------"-'-.
<br />DuE TO. OR AS A CONSEOUENCE OF
<br />
<br />Interval between onsel cl"ll Cle.,!!
<br />
<br />72H
<br />
<br />Ir'lter...al t>et'Neen onsel ;:Inri (l~i-III'
<br />
<br />101
<br />DuE iCloAAS A CONSEOUENCE OF
<br />
<br />ATHEROSCLEROSIS
<br />
<br />40 v..,
<br />Inlerval u81ween onSCI and de.,n'
<br />
<br />lei
<br />PART OTHER SIGNIFICANT CONOlnM~"CC(\dilio/ls contributing 10 the de~lh bul not relaled~
<br />
<br />" PROSTATE CANCER/DIABETIC FT ULCER
<br />
<br />IDDM
<br />
<br />40 y
<br />
<br />
<br />D_Nn
<br />
<br />2'5 WAS CASE Rf.FERH~D'~D1CAL
<br />EXAMIN!:.R OR CORONER')
<br />
<br />Yes n No fl
<br />
<br />26<'1
<br />
<br />0 ACC::ld~nl 0 UMBlermlned
<br />0 SiliCide 0 Pendrng 260 INJURY AT WORK
<br />0 ~lomicide InveShgahon YesD NoD
<br /> 273 DATE OF DEATH (Mo Day Yr.)
<br />
<br />26g LOCATION
<br />
<br />STI=I17:I;;T OR R.F.D, NO
<br />
<br />CITY OR TOWN
<br />
<br />STATl::
<br />
<br />~'~-~-,-,.,-,-"
<br />?6a. [)A n= SIGNE:;D (Me; UClV Yr I
<br />
<br />26b TIME OF DEA fH
<br />
<br />A ril 27
<br />
<br />2002
<br />
<br />04-301.02
<br />
<br />3 SP . M
<br />
<br />1>~ ~
<br />~0~
<br />Cl.~l=>-
<br />~(/)~Z
<br />OlLl-O
<br />.z ~ a
<br />.oo.~ '.'
<br />C\ ::.
<br />
<br />M
<br />
<br />270. DA, TE SIGNED (Mo" Day YrJ
<br />
<br />TIME OF DE;ATH
<br />
<br />2Be f-J!40NOUNCED DEAD rMo Day. Yr,)
<br />
<br />._._-,~
<br />2Bd. PRONOUNCEO DEAD (}-fOUl'
<br />
<br />o ~
<br />~:i
<br />'~i ~
<br />3 g'o
<br />J': 0
<br />.oo~
<br />
<br />
<br />27d To the resl 01 my knowled
<br />eause(s) sIal9\:!.
<br />
<br />-~. ~
<br />26e On the basis of ellaminalion ;;:Ind Of in....eStlgation, in mv opinion decl!l1 OCCUHOO al
<br />lhe llrT1~, date and place aM due' 10 lhe cause(s} staled.
<br />
<br />NO
<br />
<br />30b WAS CONSENT GRANTED?
<br />DYES 00 NO
<br />
<br />29
<br />
<br />31
<br />
<br />Lar~_y
<br />32rl REGISTRAR'
<br />
<br />Hansen, M. D. "_~jJ 1 ~ w.
<br />. JhJtlf,a A I h'f47il'
<br />
<br />Faidley,
<br />
<br />Grand
<br />
<br />Island, NE 68803
<br />132b DATE FllEO B,y"RE:GISTRAR (Mo,. Day Yr)
<br />.1 ~ '" 1), I,' ',..... """ "" I"\"'~
<br />
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