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1. DECEDENTS -NAME (FIrst,' Middle, ': Lit, Sufis)
<br />Blayne Helen. Ruth Nonneman
<br />2. SEX
<br />-F
<br />6c. UNDER 1 DAY
<br />3. DATE OP DEATH (Mo.,Day,YI )
<br />May 5, 2013
<br />E. DATE OF BIRTH (MO. Dsy, Yr.)
<br />October 19, 1917
<br />4. CIF! AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />6a, AGE-Last Birthday
<br />(lfrs)
<br />95
<br />6b.. UNDER 1 YEAR
<br />Alma Nebraska
<br />MOS.
<br />DAYS '.
<br />HOURS;,
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER'
<br />506-09 -5225 ..
<br />6L PLACE OF DEATH
<br />HOSP AL: 0 Inpatient '. 4SHEB: Nursing Hom<C : Hoenig Ridgy
<br />❑ ER/QUtpWent ❑ Decedent's: Honer
<br />[Doss pon»ns qr)
<br />eb. FACILITY -NAME (If not lns6Wgon, gig' sheet and number)
<br />Good Samaritan Society -Grand Island Village
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />Grand. Island 68803
<br />Id. courtly OF DEATH
<br />Hall
<br />11s. RESIDENCE-STATE
<br />Nebraska
<br />0b. COUNTY ::
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />$ ET ANO NUMBER
<br />Ti � riine Street '
<br />he . APT, NO.
<br />214
<br />M . ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® Y.. ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH' ❑ Married ::❑ Never Mauled
<br />❑ . Married, but separated OD Windowed ❑ Dhrorc d 0Unknown
<br />108. NAME OF SPOUSE (Fkst, Middle, Last,. Suffix) aw1N, give =Mao IIarhe.
<br />Lawrence % <Nonneman
<br />11. FATHER'S -NAME (First - Middle, '::Last Suffix)
<br />Jess Beachler
<br />12. MOTHER'S -NAME (First, Paddle., Maiden Surname)
<br />Margaret Schroeder
<br />13. EVER IN U.S. ARMED FORCES? Give dates or s.MeaIf Yes.
<br />(Y.., No, or Unk.) No
<br />14a. INFORMANT -NAME :
<br />Kim Mettenbrink
<br />148. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />16. METHOD OF DI8POSmON
<br />®aud.l ❑ 0onulon ,
<br />❑cnrn.non >,❑Enroe, t
<br />❑ c] OIIs�lBPrcXY)
<br />LJ
<br />16.. ER- SIGNATURE
<br />1 irait c_=
<br />16b. LICENSE NO.
<br />/0 9 7
<br />16c. DATE (Mo., Day. Yr.)
<br />May 11, 2013
<br />6d..
<br />Westlawn
<br />METERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City Of Town, State) ``.
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />178. Zip Coda
<br />68801
<br />.. CAUSE OF DEATH (See Instructions and examples)
<br />11. PART L R o w I I 4 stoOttafAMOD - dissents, InjrM.,.w c0 0 io.. -Drat directly tamed du 1146*,. 00 N0746N10n.I events such as cannon anew, '. APPROXWATE INTERVAL
<br />n.prnta.y ann.. nrvs,adndvIt 0Imbn wr, tsowingtM •telooy. 00 NOTAURMATE Enter **V en. : wer on rrw Add addransi Ones Y n.awry.
<br />..: IMMELIA , .' .. :onset to MNh
<br />IMMEDIATE CAUSE (Final : _ I Z1u
<br />distrait, or condHOn resulgnp 6 ) /i „. , � �
<br />In death) - I�-���
<br />DUE TO, OR AS A CONSEQUENCE OF: • I Onset te death
<br />any, atlally t conditions,
<br />cause b) V LJ /- f €
<br />•
<br />eny, loading p theeeua Meted. i•• J
<br />on 000 a. ' DUE TO, OR AS A: OF: ; , onset to death
<br />Enterthe UNDERLYING CAUSE - el
<br />(disease or injury that initiatsd
<br />Ns avant* resulting In death) DUETO.OR AS A CONSEQUENCE OF: to tleath
<br />LAST
<br />d)
<br />18. PART E OTHER SIGNIFICANT CONDm0NS•Conditlon• OOnMO.41ng 10 the damn But not mulling M the und4Ayk.g cageo given: in PART L
<br />16. WAS: MEDICAL EXAMINER
<br />OR CORONE CENITACTED7
<br />❑ YES 5
<br />,2200. t EMMALE: :
<br />t;jNOe pregnant wain pat year
<br />❑Pregnant at time or dam
<br />❑ Not pregnant, but gagmen within 42 days Of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unlwown R pregnant within the pat yen
<br />, 211a .M/ MANNER OF DEATH
<br />' [!'Natural ❑ Homicide
<br />❑ Accident ❑ Pending Inwistlgation
<br />❑ Suicide ❑ Could not 8. determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driwr/Oparator
<br />: ❑ Paeeenger
<br />❑ P.d..t�ae
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY P510FORMED?
<br />❑ YES ': 150.
<br />;
<br />ltd. WERE PL E A E OF AVAILABLE
<br />TO COMPtETE CAUSE DEATH?
<br />❑ YES : [j 0 / ,
<br />22.. DATE OF INJURY (Mo., Day, Yr.)
<br />I.228. TIME OF INJURY
<br />m
<br />22e. PUKE OF INJURY -At hone, farm, skeet, factory, office building. construction site, etc. (Sp•cIN)
<br />22d. INJURY AT ?
<br />❑ YES co
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY - STREET 4 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />NI
<br />F ° 238.
<br />s
<br />23a. DATE OF DEATH. (Mo., Day. Yr.)
<br />May 5, 2013
<br />�Y III Z ���
<br />w
<br />$ p
<br />24e. DATE SIGNED (Mo. Day. Yr.)
<br />248. TIME OF DEATH
<br />DATE SIGNED (Moe, Day, Yr.)
<br />. May 9, 2013
<br />23.. TIME O F DEATH
<br />1.55
<br />24o. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. T the est of my. knowledge, death ocomn time, d at the e: dap and gees
<br />$ 1 the se(*) . (Signature MCI Ti�cey'---
<br />24e. On the id
<br />r be of examination 1ndlor Investigon, In rry opinion death occurred
<br />at 1M time, data and plea end due to the cauee(a) stated. (Signature and TIU.)
<br />26.01D TOBA US NTRIBUTE TO THE D TN?
<br />YES t 13 PROBABLY ;,)a
<br />26a.. HAS ORGAN. OR TISSUE pDp� "� TION BEEN CONSIDERED?
<br />❑ Yes Lt- 0 ,
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26e Is NO ❑ YES
<br />27. NAME, TITLE AND ADORES' OF CERTIFIER (Type or Pried)
<br />John A. Wagoner, M.U., 800 Alpha St., Grand Island NE 68803
<br />26a'REOISTRAR'8 SIGNATURE l � )
<br />Arr
<br />2813, DATE FILED BY REGISTRAR HMO. Ds/. TO
<br />MAY 13 2013
<br />DATE OF ISSUANCE
<br />05/15/2013
<br />LINCOLN, NEBRASKA
<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 />•
<br />201403151
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />n Cb rICIAATe V 11 ATU
<br />STANLEY S. COOPER:
<br />ASSISTARIT STATE REGISTRAR
<br />DEP,4TTMEN T OF HEALTH AND-
<br />HUMAN S' ICCS,
<br />13
<br />365
<br />
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