|
� �.
<br />'STAT� NEBRASKA ,
<br />1 r
<br />, WHEN THIS COPY CARRIES THE RAISED SEAL OF TKE IVFBRkSKA DEPARTMENT OF HEALTH �4N�7 ,�jClMAN SE
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL I2ECORD ON FILE WITH THE NEBRASKA 0',� „� _ T .(� � L�{'U7`.0
<br />HUMAN SERVICES� VlTAL RECORDS OFFICE, WHICH IS THE �E�AL DEPO5ITORY FOR V1T�1I�"`��C�lJ�.'::�w�
<br />DATE OF ISSUANCE
<br />��� 3 � zoo�
<br />_ LI�(CDLI�_NEBRASKA _
<br />201105910
<br />`
<br />. � �� ;.�.�.*'�
<br />; �, :; .
<br />�� h 9 ': f :� :
<br />: � �s� . "m / 4 ,< .
<br />STATE OF PIEBRASKA- DEPARTMENT OF HEALTH AN17 HUMAN 3ERVICES FlNANCE ANtl $l��T �' �� c�t
<br />CERTIFICATE OF DEATH ' v � : ,, �,��.,
<br />o ' • ``
<br />JO�
<br />RVICE5,17" CERTIFIES
<br />�f H��IL,TH'A�ND
<br />�'
<br />��� �,. > H , �
<br />y �'� '�; d
<br />� �I „� �Y �} F.
<br />�{ T y 3 I 5, �,
<br />��r� u,.
<br />�� �y
<br />_�:�� _ _
<br />= �,�
<br />(''j � �
<br />G7
<br />y �v ,
<br />�1> .�;,�
<br />1. DECEDENTS•NAME (Firat, Middle, Leat, 6ufflx� 2. SEX ��3.bkj80FD ]'H.jMa,,bay,Yr.)
<br />Walter Albert Meinecke Male � Sept�mr�er�23,-2008
<br />4. CITY AND STATE OR TERRITORY, OR FOREIaN COUNTRY OF BIRTH 5a. AGELast Birthday 5b. UNDER 1 YEAR So. UNDER 1 DAY B OF BIRTH (hAq„D�y, Yr.)
<br />(Yrs.) 89 MOS. DAY9 HOURS M�NB. Jul 21 � 1 ��}9�9-
<br />Saint Libory, Nebraska y
<br />7. SOCIAL SECURITY NUb1BEq 8a. PLACE Or DEATH �
<br />505 HOSPITAL ❑ ioPan�n � �e�r8m9+�o�to i�N�����m
<br />Bb. FACILITY-NAME (If aat inetitutlon, give atreet end number) ❑ ER/OutpaUent ❑ DeoedenCeHome
<br />Heritage Living Center ❑ ar, ❑om�,�s��
<br />8c. CITY OR TOWN OF DEATH (Indude Zip Code) 8d. COUNTY OF DEATH ��'
<br />St. Paul, Nebraska Howard
<br />8a. RE8IDENCE-STATE 9b. COUMY 8c. CiTY ORTOWN
<br />Nebraska � Howard St. Paul
<br />BdSTREETANDNUMBER Be.APT.NO Bt.ZIPC00E Bg.IN31DECITYLIMIT3
<br />920 Jackson 68873 � rES ❑ No
<br />10a. MARITAL STATUS AT TIA7E OF DEATH ❑ EAerrled ❑ Never Marrfed tOb. NqME OF BPOUSE (Flrat, Middle, Last, SuH�C� If wife, give maiden nama.
<br />�emea ,butaeparated ❑Widowad ❑owomea ❑u��no� Evelyn 0. Rleink.auf
<br />i t. FATHER•3-NAME (First, _ Mldd�e, Last, 9uffiz) 12. MOTHERB•NAME (Firat. Mlddie, Meiden Sumame}
<br />Henry Albert Me3.necke Qlga Helen $eckman
<br />13.EVERINU.S.ARMEOFO C S? t erviceMyea. 14a.INFORMANTNAME � 14b.RELATIONSHIPTODECEDENT
<br />(Yea,no;orunk.)YCS ��-����� Jack Meinecke Son
<br />15. METHOD OF DISPpS�TION 18a. EMBALMEA-SIpNqTUpE 18b. LICENSENO. 18c. DATE (Mo., Day, Yr, )
<br />❑s�� UDonatlon Not Embalmed Se tembar 24 2008
<br />� Cremadon ❑ EntombmeM 18d. CEMETEHY, CREMATORY 09 OTHER LOCATION � CITY /TOWN STATE �
<br />❑ Removel O Olher (SPecify) �• ' � � . : . . � � � .
<br />Wegt3.aw�.:� Park Crematory Grand Island, Nebraska
<br />17a.FUNERALHOMENAMEANpMAILINaADpRES$ (Street,CityorTawn,3tata) . � - - � . 17b.ZipCOde
<br />Livingston-SOnderma.nn Funeral Home 601 N. Webb Rd, Grand Island, NE 68803
<br />❑ YES ❑ NO
<br />22f.LOCATIONOFINJURY-STREET&NUMBER,APT.NO. CRY/fOWN
<br />7& PART 1. Enter the chain of erema--dlseasea, InJuries, or cpmpllcaUona-that dlrectly cauaed the death. DO NOT enier terminal evenia such as cardiac artest, APPROXIMATE INTERVAL '
<br />respiretory artest, or venbicular fibrllletlon willwut showi iha etlol �� �
<br />� ogy.DONOTABBREYIATE.Entaronlyorrecauseonal6re.�Addedditlonalllneatlneceseary. �
<br />IMMEDIATECAUSE �. onaettodeath
<br />J
<br />mm�marecaus�c� -(� G �tz.o�uc �r+xt�!,�„ �
<br />�°�����8 DUETO,ORASACONSE�UENCEOF: � I onaetfodeath
<br />Ind�fit). � � �
<br />I
<br />�N���Y���d�one.fl N1 �N�=Mtl+ I
<br />�'�A����� DUETO,OflASACONSEQUENCEOF: � � � � � I
<br />i onaettodeath
<br />on0�rea� . � ,
<br />ErderthBUNDERLYMQCAUSE �
<br />��m�, ��� L Y n�nr-��,� a. �
<br />������ DUETO,ORA3ACONSEQUENCEOF: � onsetwdeath
<br />Ul4f
<br />I
<br />�� I
<br />. 18. PART IL OTHER�3t4NIFICANi CONpITION&COnditions cpnt8buting to the death but nM resuiting in Ne undedy�ng ceuse ghren In PART I. 18. WA3 MEDICAL EXAMINER
<br />ORCOflONERCONTACTEO?
<br />❑ YES NO
<br />ZO:IFFEA7ALE: 21aN�� 21b.IFFRANSPORTADONINJUHY 21aWASANAUTOP3YPERFORMED7
<br />❑ Not pregnant within peat year • ,. , '�l`�� IIHamidde ❑ DrivadOparator �
<br />❑ Pregnant et time ot death ❑ Acciderrt0 ParMhre ImesUgatlon
<br />ClPassenger ❑ YES �NO
<br />❑ Not pregnent, but pregnaM wHhin 42 days of tleatb � � P � e �� 21tl. WEREAUTOP3Y FlNDIN6S AYAIIABLETO
<br />❑s�mde ❑CovldnotbedetermUred �Other(Specify)
<br />0 NM pregnant, but pre{�nant 43 tlays to 1 yeat 6eFore death COMPLETE CAU9E OFDEATFI?
<br />❑ Unknownifpregnantwithinthepeatyear , � - . ❑ YES • 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.J 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, sUeet, factory, office builtling, ¢onsWCNon e�te, eto. (Specily)
<br />m
<br />-°-- - - _ -- --°-
<br />22d.�NJURYATWORK?, 22e.DESCRIBEHOWINJUHYOCCURRED � �
<br />��2tS7 V PHi R. ����V �j.Y.1 �w � i= M: c
<br />28e.RE0137RAR'SSIGNATURE ',�.�., � 1 /
<br />SDQE ZIPCODE
<br />23e.DATE0FDE4TH (Mo.,Day,Yr.) � � � � 24a.DATESIQNED (Mo.,�ay,Yr:) 24b.TIMEOFDEATH -
<br />,�' �C7f �".. (�� � ZU�� �+. � Rl
<br />� 23b.0ATE 0(Mo., aq,Yr.) �/ 23c.TIMEOFDEATH ��� 24c.PRONOUNCEDOEAD(Mo.,Day,Yr.) 24d.TIMEPRONOUNCEDDEAD
<br />�p l Z� Z�bK � � �p an6>
<br />Em � m
<br />�� $� 23d. To the best ot my Imow edge, deaih occurr� at the tlme, date e� plece $�ii �� 24e. On the besis of exeminadon end/or imestlgallon, in my opinlon death occurred at
<br />� � and teted. (Signature and Tltle )� � o p p the Hme, date end piaca end dueto the cause(s) atated. (SlgnaWre and Tlde )♦
<br />a �/ F ° C ��
<br />Y .:,., � ,� 8 s
<br />26.DIDTOBACCO U$ECANTRIBUTETOTHE DEATH4 28a. HA3 ORQAN OR TIS3UE DONATION BEEN CON3IDEREO? 28b. WAS CONSENT ORANTED?
<br />❑ YE8 ,�,NO ❑ PROBABLY 0 UNKNOWN ❑ YE3 O Not Appliceble if 28a ia NO ❑ YES ❑ NO
<br />27.NAME,TfTLEAPIDAt3DRESSOFCERTIFlER (PHYSICIAN,CORONER'SPHYSICUINORCOUNTYATTORNEI��(fypearPrint� - . � � - �
<br />. r��� ivz.r. ca����
<br />28b.DATEFILEDBYRE013TRAR (Ma,Day,Yr.)
<br />SEP 2 6 200�
<br />•
<br />d
<br />HHS-81 11/03 (55061)
<br />
|