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v1∎ 1 10 I,Jr I I.. v■ or •• • • •
<br />1. DECEDENTS -NAME (First,., Middle, :.: 1.a1 Suffix) :
<br />Norma Jean Mettenbrink
<br />,.
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />Aril 10, 2013
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Amherst, Nebraska
<br />6a AGE -Last Birthday
<br />(Yrs.)
<br />84
<br />6b. UNDER 1 YEAR
<br />6c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo.. Day. Yr .
<br />August 2, 1928
<br />: 140S.
<br />DAYS -
<br />HOURS'.
<br />MINE.
<br />... 7. SOCIAL :SECURITY NUMBER
<br />507-32 -8689
<br />6a PLACE OF DEATH
<br />tt44ffiAL: ❑ Inpat..d 4Tl=IZI Nursing Home/LTC ::. D Hoapics Facility
<br />:
<br />❑ ER/Outpatient ❑ Daeadenrs Home
<br />0 DOA 0 0 hm(8paeNy)
<br />8b. FACILITY-NAME (I not Institution, give 'bast and !lumbar)
<br />Wedgewood Care Center
<br />6c. CITY OR TOWN OF DEATH (India Zip Code) :
<br />Grand Island 68803
<br />Id. COUNTY OF DEATH
<br />Hall
<br />Sa: RESIDENCE -STATE
<br />Nebraska
<br />Ob. COUNTY
<br />Hall
<br />90. CRY OR TOWN
<br />' Grand Island
<br />Id. STREET AND NUMBER
<br />1498 East 1 -R Road
<br />W. APT, NO.
<br />91. ZIP CODE
<br />68803
<br />ag. INSIDE CITY LIMITS
<br />❑ Yes ® NO
<br />10a. MARITAL STATUS AT T1ME OF DEATH ❑ Marded : ❑ Never Married
<br />r ° Uan.d. but . sparated El WId°Wad ❑ DIvoresd ❑ U'llmawn
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) SLAIN. gale maiden name.
<br />I Elmer W Mettenbrink -
<br />11. FATHER'S -NAME (First, : Middl Last Suffix)
<br />Edward Hartmann
<br />12. MOTHER'S -NAME (First Middle. Maiden Surname)
<br />Myrtletta Siebke
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Y, No, or Unit) No
<br />14a. INFORMANT -NAME T
<br />Deb Shafer
<br />14b. RELATIONSHIP TO DECEDENT
<br />Dau liter
<br />16. METHOD OF DISPOSITION
<br />°°"
<br />® emir ❑"""
<br />Ontonagon t tombment
<br />❑m..•, ❑ottNnsp.c'yl
<br />16a. EM ER-SIGNATURE •
<br />64. lt Ja -t•t h� 7e^
<br />'Mb. LICENSE NO.
<br />/34
<br />16,: DATE (Ma. Dar. Yr.)
<br />May 4, 2013
<br />Lid. CEMETERY REMATORY OR OTH LOCATION CITY !TOWN STATE
<br />Westlawn'Cemetery Grand Island Nebraska
<br />17a.: FUNERAL HOME NAME AND MAILING ADDRESS (Street City or Town, Stab):
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. ZIP Cods
<br />68801
<br />CAUSE OF DEATH See instructions and exam ' lee
<br />15. P I. Enna go b1DAS0011 •dlaaws. hyenas, 01wnlNC•dontsdot airway =nod the dNa6O0 NOT wear bawled WNW 11Nb IA oordt•0 anat, , APPROXIMATE INTERVAL
<br />N"Pbro afoot. et wnorkelar fibrillation wel001 Owens the Wal00. DO NOTANRIVIA1S. Enter only one cane on a rem. Add additional live if nonwary. t
<br />IMM USE:. : :onset to *oath
<br />IMMEDIATE CAUSE (Final •
<br />r (�
<br />disease or condition marking : a) //4(-/// �C7L(,.f � ... h
<br />In death) =
<br />DUE , OR AS A CONSEQUENCE OF : onset N death
<br />Ssgwntally tat condltons, t
<br />any. Lading to the cause listed.'. bl
<br />on tine a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />Enter the UNDERLYING CAUSE e)
<br />(Seem. or injury that Initiated
<br />_
<br />the event* resulting In daalh) DUE TO, OR AS A CONSEQUENCE OF: 1 °Tat r to death
<br />LAST - t
<br />:'. �..
<br />18. PART O. OTHER SIGNIFICANT CONOMONS•ConditIons contributing to the death but not faulting In tai underlying COLAs pawn In PART L
<br />1 � i
<br />19. WAS. MEDICAL NER
<br />OR CORONER ACTED?
<br />❑ YES 0
<br />N F FEMALE
<br />ot pregnant within past year
<br />❑ Pregnant at time of death
<br />❑Nos pregnant: but pregnant within 42 days of death
<br />❑Not pregnant but pregnant 43 days to 1 :year before death
<br />❑ Unknown H pr.gn.nt within the past year
<br />211 MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑: Pending InvatlpaIon
<br />❑ Suicide ❑ Could not b. determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ DrIvsrlOpsrator
<br />21C. WAS AN AUTOPSY FORMED?
<br />❑ VES
<br />❑ Passenger
<br />❑ P.desWart
<br />❑ Oihar.(SPecly)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />: TO COMPLETE CAUSE . OF DEATH?
<br />❑ YES
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />220.11ME OF INJURY
<br />T '
<br />22e. PLACE: OF INJURY -At home, farm, street factory, office building, construction sib, etc. (Specify)
<br />22d. INJURY AT t I(?
<br />❑ YES 'NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />1
<br />23a. DATE OF DEATH (Mo., Day, Yr.) Z 24.. DATE SIGNED (Mo., Day, Yr.)
<br />A ril 10,' 2013 �g
<br />: 24b. TIME OF DEATH
<br />G 23b. DATE SIGNED (Mo., Day, Yr.)
<br />A. i 2013
<br />23c. TIME OF D EATH >. 24e. PRONOUNCED DEAD (Mo, Day. Yr.)
<br />8:40 • ,n i e
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />10C�
<br />ro bt o1 my knovdedpb. death oacurtW al tai 1 E Ent date and place 5 24e. On the basis of examination and/or invesdgaton, in my opinion Math occurred
<br />bowl
<br />to the eau s) • (Sipnarw.and Tmq B. C m at the time, dale and place and due tote mourns) stated. (m � gne and Title)
<br />en o
<br />26. DID: • 0 USE CONTRIBUTE, 5 DEATH?
<br />YES NO ❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR 11SS E DONATION BEEN CONSIDERED?
<br />❑ YES ' 'I NO
<br />260. WAS CONSENT GRANTED?
<br />NotAppliCabl. I ass is 0 YES - t NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type: or Print)
<br />John Wagoner M.D. 800N. Alpha St'. .. Grand Island, NE 68803
<br />26a. REGISTRAR'S SIGNATURE ► f
<br />26b. DATE Q B REGISTRAR (Mo., Dry, Yr.)
<br />APR fpA(901
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />E
<br />0
<br />DATE OF ISSUANCE
<br />04/24/2013
<br />LINCOLN, NEBRASKA
<br />201303826
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES'
<br />a►c STIITI#SwT @;.f.r F ATMJ
<br />STANLEY S. COOPER
<br />ASSISTANT STATE- REGISTRAR
<br />DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICE'
<br />23067,
<br />
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