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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANQ (�iUMi4N� SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA f�1L�PARTiN1�/N�'.'QF, HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR" I/1'7���REC`b,�DS�. "�,;; .',' „
<br />` �' � .. �
<br />DATE OF ISSUANCE ,��/���� � ��' �
<br />09/20/2010 � � � 2 � � � � � sr�ter�s� �ovp�r�,° : � ' �;
<br />ASSI�TANT 57`,,I/ 7�',R,��C. ISTRiAR;' �
<br />DE�.4RTMENT OF HEALTH , •° ,
<br />LINCOLN, NEBRASKA HUP'j�lU,S . ' r� '
<br />, y,.. .• , .'�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE�S � r y� � i I�';�-�','.� '� �'� �' ��� 10 02566
<br />...-.��.�....�.- ..� .. .r.. ,5 s . ..... .,,
<br />a.�R��rn.ri��vrvrr��n � .�h � . •, � ..
<br />1. DECEDENTS-NAME (Flrst, Middle, Laet, Suftlx) 2. SIX .- �3, bATE OF DEATH (Mo., Day, YrJ
<br />Marlanne NMI Manning Female 5eptember 12, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS M9NS.
<br />North Hollywood, Califomia 53 April 19, 1957
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />564-23-7392 HOSPITAL � InpaUe� OTHER � Nural�g HomeILTC � Hospice Faclllly
<br />8b. FACILfTY•NAME pf not Inatitution, give street and number) ER/O
<br />� ❑ utpaUe�rt Q DecedenPa Home
<br />� St. Francis Memorlal Health Center LTC ❑ oon ❑ Other (Specify)
<br />�
<br />� ec. CITY OR TOWN OF DEATH �netude Zip Code) Bd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE 9b. COUNTY 8c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />LL 8d. STREET AND NUMBER e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />a 1203 Kennedy Drive 68803 � r�s ❑ No
<br />a 10a. MARRAL STATUS AT TIME OF DEATH � Marrled Q Never Marrled 10b. NAME OF SPOUSE (FUst, Middle, I.aet, Suffix) IiwHe, glve maiden rmme
<br />� ❑ nnamea but separated ❑ �nnaowea ❑ Dhroreed ❑ Unknown Steven Manning
<br />m
<br />� 17. FATHER'S�NAME (Flrst, Mlddle, Last, SuHiu) 12. MOTHER'S•NAME (Flrst, Mlddle, Malden Surmame)
<br />m Raymond Graf Margaret Jones
<br />°' 13. EVER IN U.S. ARMED FORCES7 Glve dates oi servlce R Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ �rw, No, or uru�.� No Steve Manning Husband
<br />,$ 15� METHOD OF DISPOSITION 18a. EMBALMERSIONATURE 18b. LICENSE NO. 18c. DA7E (Mo., Day, Yr.)
<br />F ❑ Burlal ❑ Do�tlon
<br />Not Embalmed September 13, 2010
<br />� Crematton ❑ F.ntombment �Bd. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removai ❑ Other {Speelfy) Central Nebraska CremaUon Services Gfbbon Nebraska
<br />7Ta. FUNERAL HOME NAME AND MAILINO ADDRESS (Street, City or Town, Sfate) 17b. Zip Code
<br />All Fafths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF D T See instructlons and exam les
<br />1& PART L Fster tlre ehaln W ereMe--0ISeasee, Injuriea, or complicatlons�that tllreWy pusad fhe deeth. DO NOT e�rter terminal eve�rte sueh ea eardiac artest, ; APPROXIMATE INTERVAL
<br />� reaplretory arteat, or vemricular flbrillatlon wlthout ehawing the etlology. DO N0T ABBREVINTE Emer only one eauw on a U�re. Add additlorml Wree H �recesaary.
<br />IMMEDIATE CAUSE: ; onset W death
<br />unan�owre cause �Fi� e) Metastatic Breast Cancer s Months
<br />dlaease or comllUon resuitlng
<br />� d �� DUE TO, OR AS A CONSEQUENCE OF: ' onset to death
<br />SequeMialfy Iiat condlUone, li b)
<br />e�, leading to Ne cauw IlsOed
<br />on nne a DUE TO, OR AS A CONSEQUENCE OF: : orreet to death
<br />Enter the UNDERI.YINO CAUBE C �
<br />(Uisease or InJury that inftha0ed
<br />ma eveme resuttlne In dead�) DUE TO, OR AS A CONSEQUENCE OF: � o�et to death
<br />� d)
<br />18. PART II.OTHER SIGNIFlCANT CONDRIONS-CondlUore coMributlng to tha death but not reauiting In the urttlartyine �uae given In PART I. 18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />a , ❑ YES � NO
<br />W O. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED9
<br />�
<br />� � Not pre8� �n past yaar � Natural � Homldtla � DrivedOperator ��S � NO
<br />v � r�a�+e � n� m a�u, 0 n,xmaM � Pending InvestlBatlon ❑��"e�
<br />� NM pree�eM, but pregnam wtthln 47 deys oi ueath � PedeatNan 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />'� a Nat pregnaM, but pregnaM 49 tlaye l0 7 year befora death ❑$Welde � Coultl not be determUred ❑ � r s TO COMPLETE CAUSE OF DEATHI
<br />( PB�Y)
<br />� ❑ res ❑ No
<br />� ❑ unknownlrpragnamwkhlnthepaetyear
<br />°' 22a. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, Tarm, atreet, faetory, offlee butiding, W�vetlon site, ete. (Specfty)
<br />E
<br />�
<br />.� 22d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />� ❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (MO., Day, Yr.) 24b. TIME OF DEATH
<br />B � Septamber 12, 2010 ,� � �
<br />� � Y 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� y 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z Se tember 13, 2010 0820 PM g a�
<br />�� 0 . To the beat oi my knowled8e, death occurted at the tlme, date an0 ptace $ � 24e. On the haste at examinsGon and/or imeafigadon, in my apinWn daath accurred at
<br />and due to fha cause�s) sialed. �SiB�mtura aiM Tltie) $� the tlme, tlate end p�ace aiM due to the cause►a) etatetl. (Signature and Tltle)
<br />~� Chad Vieth, MD ~ g s a
<br />25, DID TOBACCO USE CONTRIBUTE TO THE �EATH? 28a. HAS ORCRAN OR TISSUE DONA770N BEEPI CONSIDERED? 28h. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applteable If 28a Is NO ❑ YES ❑ NO
<br />2, E, TITLE D D O C TIF (P UW IST T, ORO 3 Y I R C ORNEY) (Type or ►IM)
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'9 SIGNATURE �- � 28b. DATE FlLED BY REGI9TRAR (Mo., Day, Yr.)
<br />September 14, 2010
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