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<br />STATE OF' NEBRASKA
<br />� ,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF TME NEBRASKA DEPARTMENT OF hl�A4TM'ANl�f��l,�'�K�'I�'�S� �'� CERTIF'IES
<br />T►HE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB��'lCq,;�A�?�F�Epl7' �� kl�At'TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH I$ THE' LEGAL DEPpSITORY FQR V�14 �bRR$: '•� `.� � x
<br />DAT� �F ISSUANCE - �� � s
<br />�� ,
<br />�oioaso57 �T.��Y� :-����
<br />12/08/2009 ;4s5r��.4n�T S�A�'��€��57'RAt�'�, y �,?
<br />oEPa�rM�nr� �� r��,��r�r �3` �
<br />LINCOLN, NEBRASKA HUMAN,S�RVI�'�,�; � �� �
<br />STATE OF NEBRASKA - pEPARTMENT OF HEALTH qND HUMAN SERVIGES;'° •�' ��'t �. �.: r.•�". ' �"O9 D�T� �
<br />�re�T�r��w�w� .ti�e.��w:w�rY�� .., .�.. . . . � ...
<br />VGRIIr1�rMIG..tiJf'LJGMIfI � �.iT •-...
<br />1. DECEDENT'S-NAME (Flrst, Mlddle, Last Suttlx) 2. sEX 3'CA7E`OF BFATt1'(Mo., Day, Yr.)
<br />Lee Ro Marvin Holtmeler ' Male Novembe�'22, 20p9
<br />A. CITY AN� STATE OR TERRITORY, pR FOREIGN COUNTRY OF BIRTH ' a. AGE - Last 6lrthday b. UNDER 7 YEAR 5C. 4NDER 7 DAY e. �AT� OF,eIRTFi (Mo., Day, Yr.)
<br />(Yrs.) MQS. DAY$ HOURS MINS.
<br />Tobias, Nebraska 74 August 30, 1935
<br />7. $OCIAL $ECURITY NUMBER ea. PI.ACE OF UEATH
<br />505-52-4921 �� � InpAGor�t dTHER ❑ Nursing Homa/LTC � Hoapic9 FaCility
<br />86. FACIUTY•NAME (li not InstlWtlon, qWa aVeet and number) � EqlOutpatlent � oecedam's Home
<br />�
<br />v 3144 Woodridge Blvd Q DOA ❑ Othar (Specliy)
<br />� 8c. CITY OR TOWN OF DEATH (Inclutlq Zlp Cpj�� r _ F w F , 8d. COUNTY QF DEATH
<br />'o Grand Island 68801 Hatl
<br />� � 9a. RESIOENCESTATE 9b. COUNTY 9c. CITY OR TpWN
<br />Nebraska Hall Grand Island
<br />LL 8d. S7REET AND NUM6ER 9B. APT, NO. 9/. ZIP CODE 9g. IN51�� CI7Y LIMITS
<br />�, 3144 Woodrid e Blvd gggp1 � YES ❑ No
<br />a 10a. MARITAI. STATUS AT TIME OF �EATH � Marrlad ❑ Never AAarrlad 106. NAME qF $POUSE (First, Middla, Laet, Suffix) R wlfe, pive malden name
<br />�
<br />!� ❑ Manled, but saparated ❑ Widowad ❑ �ivorced ❑ Unknown N(I��a Jeanie Kotas
<br />m
<br />� 11. FA7"HER'S-NAME (Flrat, Middla, l.ast, Suffix) 72. MOTNER'S-NAME (Firat, Middle, Maiden Surname)
<br />� Albert Holtmeier Hermine Meyer
<br />� �' 13. EVER IN U.S. ARME� FORCE37 Glve dates oi servlca If Yas. 74a. INFORMANT-NAME 14b. RELATIONSHIP TO DECED�NT
<br />(Yea, Na, or unk.) No Jeanie Holtmeier Wife
<br />g 75, METHOD OF �ISPOSITION 76a. EMeALMERSIGNATUR� 18b. LICENSE Np. 18C. pATE (Mo., Day, Yr.)
<br />� � Burial ❑ ponatlon paniel p Naranjo 1071 November 28, 2009
<br />❑ Cremation ❑ Entom6ment �6d. CEMETERY, CREMA70RY pR pTHER L�CATION CI7Y / TOWN STATE
<br />❑ Removal ❑ OthaY (SpeClfy)
<br />Grand Island City Gemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRE33 (Street, City or Town, State) 176. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Strest, Grand Island, Nebraska 68801
<br />A F DEATH See instructions and exam les
<br />18. PART I. Enter the chain o( avente•�tliieaset, inJuYiab, oY compllCationa-that dlrectty caused [he death, p0 NO7 ente� taYminal avanta such as cardiac arreal, ; APPRpXIMATE INTERVAL
<br />rosplretory arroqt, O� ventdCUla� flbYlllation with0ut ehowlnp tha Wloloqy. DO NOT ABBREVIATE. Enter Only ona Ceuae on a Ilrw. Add additlonal Ilnea If nacassary.
<br />IMM�pIATE CAUSE: ; onset to daath
<br />IMMEDIATE CAl15E (Flnal a) Matastatic non small cell Lung Cancer ; 18 Month
<br />eiseeea ar Co�dltion rvaultlny
<br />in dwth� DIIE T'Q, OR AS A CON$EQUENCE OF: ; onset to death
<br />Saquentlalty Ilst cpndklon6, If b)
<br />any, laadlnp [o tha pu6e Ildted
<br />On line a.
<br />�UE TO, OR AS A CONS�QUENC� pF: ; onset to death
<br />Entrr ihe 11NDERLYIN6 CAUSE C �
<br />(dlseasa orinJury thatlnitlated
<br />tha avanta reaul[Inp In daath) DUE TO, OR AS A CONSEQUENCE OF: ', onset to daath
<br />usr d) _
<br />18. PART II.OTHER SIGNIFICANT CONDI710NS-Condltlons contrl6uting to tha death but not resWting In the underrying cause glven In PqRT I. 19. WA5 MEDICAL EXAMINER
<br />4R CORONER CONTACTED7
<br />y � YES ❑ NO
<br />W 20. IF FEMALE: 27a. MANN�R OP DEqTM 27b. IF TRANSPpRTATION INJUR 27C. WlA5 AN AUTOP5Y PERFORMED7
<br />LL
<br />� � Not prrpnant wlthln past year � NAtural � Homlclde � UAverlOporator Q YES � NO
<br />� � Pnqnant at tlmp of dsa[h � qCddent � Prndinq Inveatlgatlon ❑ Pasarnper
<br />T � Not pregndqt, b�H qfBgPdnt withlrl 42 dayo of death � Pedestdan 21d. WERE AUTOP$Y FINDINGS AVAILABLE
<br />� � Sulclda � CoWp not be datrrminad TO COMPLETE CAUSE OF p�ATH7
<br />� � Nat prognant, but pr0pndnt 43 ddy6 t0 1 yOiY b0f0�B tlBath � Othar ($pBClfy)
<br />� � Unknown If prvpnant wlthin tha past yea� ❑ YE5 � NO
<br />� 22a. UA7� QF INJURY (MO., Day, Yr.) 22p. TIME OF INJURY 22c. PLACE pF INJURY-At home, farm, street, factory, offlce hullding, constructlqn site, etc. (SpecHy)
<br />s
<br />,°� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY QCCURREQ
<br />0
<br />� ❑ YES ❑ NO
<br />22f, LOCATION OF INJl1RY • S7REET & NIJMeER, APT.NO. CITYITOWN 5TATE ZIP GODE
<br />23a. pATE OF DEATH �Mo., �ay, Yr.) Z � 24a. OATE SIGNED (Mp„ Day, Yr.) 24b. TIME OF UEA7H
<br />� W November 22, 2009 � � �
<br />� LL 23b. DATE SIGNEO (MO., Day, Yr.) 23c. TIME OF DEATH �� k� 24c. PR4NOUNCE� pEAD (MO., Day, Yr.) 24d. TIME PRONOl1NCED oe,4�
<br />g�-+ November 23, 2009 01:00 AM g a �
<br />��� �d. 7o tha W�t of my knowlydpa, drath accurrod at tha tlma, date and plac9 $��� yqa, On tha 6aala of axaminaUon andlpr InvB6tlgallon, In my opini0n daeth vcwned at
<br />o and dua ta tha causa�a� atatad. (Slpnature and TIt1e) �� p tlla time, dato and placa and dua to Ihe nusa(a) stated. (Slgnalure anp 71da)
<br />~ � Travis S. Hagemen, MD ~ ;
<br />25. DID T08ACC0 USE CONTRIBUTE TO THE DEATH? 26a. HA3 ORGAN OR TISSU� DONATION BEEN CONSIDERED7 26b. WAS CONSENT GRANTED7
<br />❑ YES ❑ NO ❑ PROBAeLY � UNKNOWN ❑ YES � NO Not Appllcable Ii 26a is NO ❑ YES ❑ NO
<br />. N , ITLE A D AN I TANT, ( ype or rint)
<br />7ravis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 24, 2009
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