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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, /T CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD-QN FlLF_1W"H THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISMCMO fdGFfI~3H l5 THE LEGAL DEPOSITORY FOR VITA/ ~ ~ DATE OF ISSUANCE 2 01"M ( 9/14/2004 ANLELrSpG 9PPPER /C$sl T!4f # 1$RAR LINCOLN, NEBRASKA HEALTH AND HUMAN StER - StEM STATE OF NEBRASKA- DEPARTMENT OF BEALTH AND I•IU7MAN SBIiVICEM W~OMAIWtWORT VITAL STATISTICS CERTIFICATE OF DEATH w 0 4 0 9 0 9 1 1. DECEDENT • NAME FIRST MIDDLE LAST .2. SEX 3. DATE OF DEATH /Month. Day. Year) Eatricia Ann Meister Female September 05, 2004 4. CITY AND STATE OF BIRTH I foot in U.S.A.. name country) 5a. AGE • Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Mong1, Day Year) (Yrs,) 5b. MOS. PAYS 5c. HOURS' MINS. Greeley Coun Nebraska 81 Jul 28 1923 7, SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH Nursing Home 506-42-4722 HOSPITAL: Inpatient OTHER 11 8b. FACILITY - Name (ft not instiaition, give street and number) ❑ ER Outpatlent ❑ Res.dence St. Francis Medical Center ❑ DOA ❑ Other t8pecrtw 8C. CITY, TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island Yes A No ❑ Hall 9a. RESIDENCE • STATE go. COUNTY 9c. CITY, TOWN OR LOCATION 9d, STREET AND NUMBER /including Zip Cade) 9e. INSIDE CITY LIMITS ❑ Nebraska all Gra Island 918 W 12th St. 68801 Yes ;&N. 10. RACE - (e.g., White, Black, American Indian, 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) 12. MARRIED 11 WIDOWED 13, NAME OF SPOUSE /ft wife. give maiden name) etc.) (Specify) (Specify) I/M NEVER DIVORCED White ~ Americ CiMAERIED-171 John A. Meister 14a. USUAL OCCUPATION /Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) of working liM, even Xretired/ Elementary or Secondary 10-12) College (1 •4 or 5-1 Owner/ r Child 7Da Care 12 16, FATHER - NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Frank NMI Nealon Anna (NMI) Trella 16. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT-NAME (Yea, np, gr unk,) (If yes. gwa war and dates of services) NA ~ fob A. Meister 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 20. EM (~L-MSy'E~R - IG ~TU)E 6 LICENSE NO, 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME ~IYJ, 1063 ~Burla( ❑ Removal 09/08/2004 Westlawn Memorial Park Cemetery 22a, FUNERAL HOME • NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Kleine Funeral Home ❑ Cremation ❑ Donation Grand Island, Nebraska 221). FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP) ] t rand Island, NE 68803 23. (MME CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (p)) Interval between onset and death PART f ~ I D R AS A CONSEQUENC OP. Iraerval between onset and death (h) DUE TO, OR AS A CONSEODENCE - Interval between onset and death I 1 (c) OTH R SIGNIFICANT CONDITIONS - Cqr~ /long CdgtnbOng to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART f f p PREGNANCY IN THE PAST 3 MONTHS? IXAMINER OR CORONER? 11 (Ages 10.541 Yes No Yes Np Yes No 26a. 26b. ATE OF INJURY /MO, Day. Yc) 26c. HOUR OF INJURY 26d. DESCRIBE HOW IN,;JRY OC RED Accident Undetermined L~qq M Suicide F] Pending 28e. INJURY AT WORK 261. Pe E %F l INJURY Y farm. street. factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ S ho 0 27a. DATE OF DEATH (Mo.. Day. Yr) 288, DATE SIGNED /MO.. Day. Yr) 28b TIME OF DEATH s Se tember 05,2004 A M H 27b. DATE SIGNED /Me.. Day. Yr.) 27c. TIME OF DEATH ` 28c. PRONOUNCED DEAD /Mo.. Day, Yr.) 28d. PRONOUNCED DEAD /Hour) i g Se temb 10 2004 0020am M M r 27d. To the best of my k owled e, death occurred at the ti e, date and place and due to the cs 28e. On the basis of examination and,or investigation, in my opinion death occurred at pause(s) stated- the time. date and place and due to the cause(s) stated. Si nature and Title) ► (Si nature and Title) ► 29. DID TOBACCO USE CON HI T O THE DEATH? 3f 1a HAS ORGAN OR TISSUE DONATION BE N CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES O ❑ UNKNOWN ❑ YES NO ❑ YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Print) Dr John A Wagoner MD 80 Alpha Grand Island,NE 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo. Qay Yr) 3 004