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<br />200901392
<br />,; STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUMAN SERVICes
<br />CERTIFICATE OF DEATH
<br />
<br />333:191
<br />
<br />1. DEOEOENrS.NAME (Ff...l, Middle, Leel, Su",x)
<br />
<br />2. SEX
<br />
<br />3. DATE OF OeATII (Mo.,Dey,Yr.)
<br />
<br />90
<br />
<br />5b. uNDER 1 YEAR
<br />MOS. I DAYS
<br />
<br />Female
<br />5~. UNDER 1 DAY
<br />
<br />1I0URS I. MINS.
<br />
<br />November 20, 2008
<br />
<br />I. DATE OF BIRTH (Mo., Dey, Yr.,
<br />
<br />Alma Johanna Meier
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUN1RY OF BIRTH
<br />',.
<br />
<br />Ie. AGE.Le.1 SfrtJ,dey
<br />(Yr..)
<br />
<br />Prosser, Nebraska
<br />
<br />r. SOCfAL SECURITY NUMBER
<br />
<br />November 18, 1918
<br />
<br />lb. FACILITY -NAME (If nolln.lllul'on, give .tre.1 Ind number,
<br />
<br />BI. PLACE OF DEATH
<br />IiQlf!IA!,; 0 Inpollenl
<br />o E~lpoll.nl
<br />DOOA
<br />
<br />9JI!m.; IXI Nur-Ing Homoll. TC
<br />o D.~d.nr. Horn.
<br />
<br />o 1I0.pl~o F""llIty
<br />
<br />507-92-1847
<br />
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<br />
<br />Montclair Nursing and Rehabilitation Center
<br />B~. CITY OR TOWN OF DEA TII (In~IUde ZIp Cod.,
<br />Omaha 68144
<br />Be. RESIDENCE.STATE
<br />
<br />o othIlf1Sp""lfy)
<br />
<br />-I Bd. COUNTY OF DEATH
<br />1 Douglas
<br />
<br />Nebraska
<br />Id. STREET AND NUMBER
<br />2525 South 135th Avenue
<br />10.. MARITAL STATUS AT nME OF DEATH 0 Mlrtl.d
<br />o Merrled, bu' ..perel.d iii WIdowed 0 Dlvo",."
<br />
<br />I 'b. COUNTY
<br />Douglas
<br />
<br />Itc. CITY OR TOwN
<br />Omaha
<br />I B., APT. NO. I If. ZIP CODE
<br />I 68144
<br />o Never Merrl.dll0b. NAME OF SPOUSE (FI..... Middle, Loet, S,,",x, II wII., give mlld.n nmno.
<br />o Unknown I
<br />
<br />I gg. INSIDE CITY LIMITS
<br />I I!I Yee 0 No
<br />
<br />11. FATHER'S.NAM! IF..... IlIdclIe, Loo.. BlIlJI!I).
<br />
<br />John Frederick Uden
<br />13. EVER IN U.S. AIl.MED FORCES? GIve dlto. of "lVl~e II Yee.1141. INFORMANT -NAME
<br />
<br />(Yee, No, or Unk.) No I John Meier
<br />18. MI!THOD OF DISPOSITION 18.. EMBALMER.SIGNATURE
<br />(jiB..... Oo.n...... ~ tJ~
<br />Denlrn.llot' D~",om""n'
<br />0"""'" 0""'"'1........)
<br />
<br />112. MOTHER'S.NAME (Flro.. Middle,
<br />I Anna Auausta Augustine
<br />
<br />M81dttn 8umamltJ
<br />
<br />14b.Il.ELAnONSIIIP TO DECEDENT
<br />Son
<br />
<br />I 1Sb. lICENS!! NO.
<br />
<br />lId. CEMETERY, CREMATORY OR OTHEIl. LOCAnON
<br />
<br />CITYITOWN
<br />Grand Island
<br />
<br />lBe. DATE (Mo., D.y, Yr.'
<br />November 24, 2008
<br />STATE
<br />
<br />/3'1 B
<br />
<br />Westlawn Memorial Park Cemetery
<br />17.. FUNERAL HOME NAME AND MAILING ADDIl.!!IS (Str.... CIty or Town, SI.to)
<br />
<br />Nebraska
<br />r7b. ZIp Cod.
<br />
<br />I 68801
<br />
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />
<br />CAU~E OF DEATH (See Instructions and examples)
<br />11. PART I. Enter th. ch"n ol_lIOitf8 . dl..."I, I~.. or campHc....oM-' Ihl. dtNdfJ .......d .. dB.th, DO MDT.ntw ..mtfnII..,..... .uch .. c.rdiIH:: anut.
<br />,..p".11tfY ~t, or Ylnbtcu1., ntm"..JCIin without .huwtna ttM ..tology. DO NOT ABBRI!VtATE. En~' ardy mm CIIUM on . HM. Add addhton.. H... If ne~."",
<br />IMMEDIATE CAUSE,
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl"eR't or condition relultlng B)
<br />In d..th)
<br />
<br />a~ p I ('an"" tl t\t.U.\I'(\ ())tll' '^'
<br />
<br />i APPROXIMATE INTERVAL
<br />I "".ello d.oth _
<br />
<br />I ""..110 dooth
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />s.qu.nllolly IIs1 ~ondlllon.,I' b)
<br />Iny, leading to the ceule IIstlld
<br />onU.......;
<br />
<br />Ol\{s fJ ~ l' 0..-
<br />
<br />DU~ TO. OR AS A CONSl!QUENCE OF:
<br />
<br />: on..t to d..th
<br />
<br />Pf<>tfl'ft6C; \Vfb Md ~rvrt. AI~elr11~S D~~\A-
<br />
<br />Enlerlhe UNDERLYING CAUSE 0)
<br />(dl..... or Injury Ihlllnlll.led
<br />Ihe ev.nls resulllng In dellh) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />.
<br />. 11. PART II. ornER SIGNIFICANT CONDlnONS..condlllonl conlrtbullng 10 the dosth bul nol. resulllng, In the undlrlylng ~lUse gl.en In PART I.
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<br />d)
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<br />! oneello d,"th
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<br />"I Z~. "~,F:~~A,~~: :':'. ',~'.' :I\"'-~ .:....."~":.,= ;.'; .',
<br />,&01 ptegn.nl wllhl~ 'PI~IY;~ "' :,,:~.: '.'
<br />. 0 Prog,;onl .1 11m. uf deolh
<br />o NOt progn.nl, bul progn.nl wllhln 42 d.ye oi doolit
<br />o Nol progn.n~' tiui progn"nI43d~y. 10 '1 ye",b~flirede.lI1 .
<br />OUnknown If proUnonl within th~ po.1 yeer '
<br />
<br />. .,...
<br />211. MANNER OF DEATH
<br />'tilN';'Unil' 0 1I0rlilclii.., .', .. ..
<br />tJ A~~lde;;1 '0 P.nding l;l'Ie.tig.tion "
<br />o Sul~'d. 0 Could nol be d;.lonnln.ii
<br />
<br />221. DATE OF lNJUIl.Y (Mo., DOV, Yr.) I 22b. TIME OF INJURY I U~. PLACE OF INJURY"AI IIome, form, I_~ f""Iory, o"'~. bulldlng, ~onotru~lIon .110, ole. (Sp~lfy)
<br />
<br />
<br />22d.INJUIl.Y ATWORK71220. DESORlaE \lOW INJURY OCCURReD
<br />DYER DNO
<br />
<br />2Zf. LOCAnON OFINJURy,.'sTRl!I!1'.NoMaER. APt, NO.
<br />
<br />CITYfTOWN
<br />
<br />ITATE
<br />
<br />liP CDDE
<br />
<br />p
<br />
<br />23.. DATE OF DEATH.(Mo., DIY. Yr,)
<br />~~ November 20. 2008 ~a~
<br />l~ -~
<br />~ 23b. DATI! SIGNED IMo., DIY, Yr.) I23C. nME OF DEA TII j ~ g >- ,~. PRONOUNCED DEAD IMo., D.y, Yr,) 24d. TIME PRONOUNCED DEAD
<br />Eo.~ he~ 1,1..001,)$ 7:35 am!:;;...: z! m
<br />1I8!'o 23d. To I'"~ beel of my knowl"!lg.. dellh o~~urrod .. Ihe 11m., d.l,;- ond pll~e ~ wz~ ~ 0 24e. On Ih. b.... of eXlmln.llon .nd/or Inveellg.Uon, In my opinion doolll o~ourred
<br />c ond .Iu.lo III. ~uee(.).I"o<I.ISlgn"uro .nd nu., .0 _ olth. Um., d.le Ind plo~o ond dU.lo th. .....C.'s_d. (Slgn.lure ond Tlllo,
<br />~,~ ..fll>>aib\' it.V ..'. '." : "~ ~l.
<br />
<br />.2&, PI.II TI:lB~CCO USE GONlll,aUTI! TO THE pEA. . TH7.. ... ..1 21.: liAS ORGAN OR nSSUE OONAnON 1I..r:EN f;:ONSI...D.E..R. ".D? l2Sb. WAS. CON8..ENT. ORAN~t)?. ,~ "
<br />..tJYES' DNO..OPROBABLY rswNII;NO\'VH.:..J,':' O~$ ".,., B.NO : ':":j ;'"..'c"'~'" .'t~IAp~lI~obl,~,li28.01'N.O',,.OY.ES DNO
<br />27. NAME!. nTLE AND ADDRESS OF CERnFIERIPHYRICIAN. CORONER'S PIIYSICIAN Oil. COUNTY AITORNI!Y) IType orplinl'" ,. . ... .... '.', At. '.. ." ..
<br />~b.tti:Ct..W.C41vO-H) .L. 9 ~q ::\sn tJ~YOS kA. MeJAkaJ Cett-~ ~ ,ve '(;8/9&
<br />
<br />280. REGISTRAIl.'S SIGNA~. '.11. ~ C'.;= ..:.,'" ,....'. .' ..._~ "~""'''''..;'. .,. .,""'''''' '. 28b. DATE FILED a'j'IlEOIITlU\R (Mo.; DOV, Yr.)
<br />
<br />~g~~' r~'i'AAr''' DEC. 032008
<br />
<br />(y" ".l,
<br />"
<br />
<br />24.. DATI! SIGNED (Mo.. OIy, Yr.)
<br />
<br />24b. nUE OF DEATH
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<br />
<br />This certi~~thiS ~u~~nt to:~e a .Lv; copy of an original record on file with Vital Statistics, Douglas County
<br />Heal~h ~ep_t.,~~alia, Nebra~!a. .9~rtrOed copies must have a raised seal in the area to the left. Reproductions
<br />OfthlS gr~~t?ettJ~cate are ~!.l.egaLc()pies. ..'
<br />
<br />Date Issue~~: ~~'.'O'li:ZOO' Registrar: Il~.j ~,;;:'
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<br />-'I'.
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