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<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTnES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC T,;iVFIICHiS.. .
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. --
<br />DATE OF ISSUANCE
<br />20050534
<br />3
<br />�ANLEY S. O
<br />3/17/2004 P R
<br />ASSISTANT - STATE I'iECihSTRM:.
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYST_E_M -
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES F1N NCE k;& +pOI3�x
<br />VITAL STATISTICS
<br />CF.R TIFT A TF. OF T)F A TT T 04 O O O O
<br />1. DECEDENT - NAME FIRST
<br />MIDDLE LAST
<br />2, SEX
<br />r
<br />Donald Eugene Meyer
<br />Male
<br />Februar y 2, 2004
<br />4. CITY AND STATE OF BIRTH lllnol in U.S.A.. name Country/
<br />PART (� /� PREGNANCY
<br />It V` ,
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER I DAY
<br />16, DATE OF BIRTH (Month, Oay. Year)
<br />Sib. MOB I DAYS
<br />1
<br />SC. HOURS MINS.
<br />Louisville, Nebraska
<br />=n
<br />(Yrs.)
<br />82
<br />October 22, 1921
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />505 -26 -0473
<br />rn
<br />HOSPITAL: ® Inpatient OTHER: ❑ Nursing Horne
<br />HO
<br />❑ Suicide Pending
<br />28e. INJURY AT WORK
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY OfMt instifrngn. give street and number)
<br />c is Medical Center
<br />Yes ❑ No ❑
<br />❑ DOA ❑ Other(Specrtvr
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH "'•"
<br />27a. DATE OF DEATH /Mo.. Day Yc)
<br />r
<br />n
<br />8s. RESIDENCE - STATE
<br />z
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (inctu&V Zip Coda)
<br />ge. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />ro
<br />Grand Island
<br />�
<br />,cn
<br />Y
<br />11. ANCESTRY leg.. Italian, Mexican. German, a1c)
<br />12. n MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (N wire give maiden name)
<br />etc.) (Specify)
<br />White
<br />(specify)
<br />German
<br />r
<br />Cz)
<br />14a. USUAL OCCUPATION (Give kind of work done dating most
<br />V
<br />(�
<br />7C
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working I // ®, even it refired)
<br />the time, date and place and due to dause(S) stated.
<br />Elementary or Secondary (0 -12) College 11 -4 or 5 -I
<br />?4
<br />(SI nature and Title
<br />Commercial Aefri'eration
<br />p
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />George Martin
<br />Meyer
<br />Pearl Margaret Jardine
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />32b. DATE FILED BY REGI TRAR /Md. Day. Yc)
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk) I pt yes give war and dates of services)
<br />Yes WWII 1942 -1945
<br />cn
<br />CD
<br />19b. INFORMANT MAILING ADDRESS ;STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />710 Gunbarrel Rd. P.O. Sox
<br />202 Grand Island, Nebraska 68801
<br />20. EMBALMER • SIGNATURE S LICENSE NO.
<br />21 A. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />❑ Burial ❑ Removal
<br />Cn
<br />Westlawn Mem. Park Crematc
<br />22a. FUNERAL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Li.vin stop- Sondermann F.H.
<br />UCremation ❑Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY
<br />OR TOWN. STATE, ZIP)
<br />601 North Webb Road Grand Island, Nebraska 68803
<br />CD
<br />h]
<br />CJ")
<br />C!)
<br />W
<br />2
<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTnES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEC T,;iVFIICHiS.. .
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. --
<br />DATE OF ISSUANCE
<br />20050534
<br />3
<br />�ANLEY S. O
<br />3/17/2004 P R
<br />ASSISTANT - STATE I'iECihSTRM:.
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYST_E_M -
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES F1N NCE k;& +pOI3�x
<br />VITAL STATISTICS
<br />CF.R TIFT A TF. OF T)F A TT T 04 O O O O
<br />1. DECEDENT - NAME FIRST
<br />MIDDLE LAST
<br />2, SEX
<br />3. DATE OF DEATH (Month. Day, Year/
<br />Donald Eugene Meyer
<br />Male
<br />Februar y 2, 2004
<br />4. CITY AND STATE OF BIRTH lllnol in U.S.A.. name Country/
<br />PART (� /� PREGNANCY
<br />It V` ,
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER I DAY
<br />16, DATE OF BIRTH (Month, Oay. Year)
<br />Sib. MOB I DAYS
<br />1
<br />SC. HOURS MINS.
<br />Louisville, Nebraska
<br />26a.
<br />(Yrs.)
<br />82
<br />October 22, 1921
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />505 -26 -0473
<br />M
<br />HOSPITAL: ® Inpatient OTHER: ❑ Nursing Horne
<br />HO
<br />❑ Suicide Pending
<br />28e. INJURY AT WORK
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY OfMt instifrngn. give street and number)
<br />c is Medical Center
<br />Yes ❑ No ❑
<br />❑ DOA ❑ Other(Specrtvr
<br />Be. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH "'•"
<br />27a. DATE OF DEATH /Mo.. Day Yc)
<br />lztusstl A.oJ_ctlil.i, �r�viu.ow.cu
<br />r n LiJ. .w LU --
<br />8s. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (inctu&V Zip Coda)
<br />ge. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />27c. TIME OF DEATH
<br />Grand Island
<br />710 Gunbarrel Rd. 68801
<br />Yes ❑ No
<br />10. RACE - leg,, White. Black. American Indian.
<br />11. ANCESTRY leg.. Italian, Mexican. German, a1c)
<br />12. n MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE (N wire give maiden name)
<br />etc.) (Specify)
<br />White
<br />(specify)
<br />German
<br />NEVER DIVORC ED
<br />Gloria T.LaRocca
<br />14a. USUAL OCCUPATION (Give kind of work done dating most
<br />°
<br />° 6
<br />14b. KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working I // ®, even it refired)
<br />the time, date and place and due to dause(S) stated.
<br />Elementary or Secondary (0 -12) College 11 -4 or 5 -I
<br />Owner
<br />(SI nature and Title
<br />Commercial Aefri'eration
<br />8th Grade
<br />16. FATHER -NAME FIRST MIDDLE
<br />LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />George Martin
<br />Meyer
<br />Pearl Margaret Jardine
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />32b. DATE FILED BY REGI TRAR /Md. Day. Yc)
<br />19a. INFORMANT - NAME
<br />(Yes. no. or unk) I pt yes give war and dates of services)
<br />Yes WWII 1942 -1945
<br />Gloria Meyer
<br />19b. INFORMANT MAILING ADDRESS ;STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />710 Gunbarrel Rd. P.O. Sox
<br />202 Grand Island, Nebraska 68801
<br />20. EMBALMER • SIGNATURE S LICENSE NO.
<br />21 A. METHOD OF DISPOSITION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />❑ Burial ❑ Removal
<br />Feb-: 2, 2004
<br />Westlawn Mem. Park Crematc
<br />22a. FUNERAL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Li.vin stop- Sondermann F.H.
<br />UCremation ❑Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY
<br />OR TOWN. STATE, ZIP)
<br />601 North Webb Road Grand Island, Nebraska 68803
<br />� LJ. iMMCU�H � C UHUSt
<br />PART
<br />(sl 1
<br />DUETO, OR AS AC
<br />DUE TO, OR AS A C
<br />I
<br />w
<br />7
<br />1r1 (ENTER ONLY ONE CAUSE PER LINE FOR lam ), AND )c))
<br />I
<br />� y
<br />I
<br />I
<br />Interval between onset and deem
<br />lot
<br />I
<br />OTHER SIGNIFICANT ONDITIONS - Conditions contrib to me eeatn but not related PART
<br />III IF FEMALE, WAS THERE A
<br />24 AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART (� /� PREGNANCY
<br />It V` ,
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'
<br />\ \
<br />)Ages 10 -54) Yes Nv
<br />Vaa No
<br />f Yes No
<br />26a.
<br />28b, DATE OF INJURY (Mo., Day. Yr.) 26c. HOUR OF INJURY
<br />26d.. DESCRIBE HOW INJURY OCCURRED
<br />❑ Accident Undetermined
<br />M
<br />❑ Suicide Pending
<br />28e. INJURY AT WORK
<br />26L office buildlrllgJUR ,& ho 0, farm. street. factory
<br />pp qq rm�1
<br />26g. LOCATION - -- � STATE
<br />❑ Homicide Investigation
<br />Yes ❑ No ❑
<br />SANDOVALr COUNTY
<br />p
<br />28a. DATE SIGNED (Mt 200441649
<br />-
<br />27a. DATE OF DEATH /Mo.. Day Yc)
<br />X � ° O � ` ;,
<br />Book -407 Page- 41649
<br />M
<br />28c. PRONOUNCED DEA 1 1
<br />27b, DATE SIGNED (Mo.. Day. Yr.)
<br />27c. TIME OF DEATH
<br />}
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<br />�
<br />12/30/2004 11:02:12 AM
<br />X --
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<br />28e. On the basis of examiriagatt -anaor Invesfiga6dn; in my opinion death occurred at
<br />file
<br />27d. To the best of my IrTwiedge, death Od ed at the time, lace and d o the
<br />°
<br />° 6
<br />nq�
<br />, ause(s) stated.
<br />the time, date and place and due to dause(S) stated.
<br />(Signature and Title) Nk R� ��-+ L M
<br />(SI nature and Title
<br />29, Dlp TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.d HAS ORGAN OR TISSUE DONATION BEEY CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />❑YES NO ❑ UNKNOWN
<br />❑ YES
<br />'( ❑ YES O
<br />31, NAME AND ADDRESS 05 CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY; (type or Print/
<br />--kph ek z� u 11� . Lt5 +,e �^ ✓ek pq e Q Ja la 41, e k%
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGI TRAR /Md. Day. Yc)
<br />FEB ` 3 2004
<br />U•
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