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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gilbert George Manning
<br />2. SEX ' -.
<br />Male
<br />4. QAt OE DEATH (Mo.,Day,Yr.)
<br />September 3, 2014
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Worms, Nebraska
<br />5a. AGE -Last Birthday
<br />(Yrs.)
<br />81
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />B. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 5, 1932
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />508 -30 -4726
<br />8a. PLACE OF DEATH
<br />nitSPITA! : ® knpae•nt OTHER; ❑ Nursing Home/LTC ❑ HospIce Facility
<br />❑ ER/Outpatient . ❑ Decedent's Home
<br />❑ DOA ❑ Oth•r(SP•°Ny)
<br />8b. FACILITY -NAME (t not institution, give street and number)
<br />Veterans Affairs Medical Center
<br />8c. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 88803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />Cochin
<br />9s. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® Yes ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH ®Manied ❑ Never Matted
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />hob. NAME OF SPOUSE (First, Middle, Last, Suffix) N wife, give maiden name.
<br />Linda Carol Quisenberry
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Leon R Mannino
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Hilda Wieck
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or UM.) Yes 01/16/1953- 01/14/1955
<br />14a. INFORMANT -NAME
<br />Linda Carol Manning
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑a°'l" l °naae°
<br />❑cremation ❑Bnembmam
<br />❑ i moyY ❑tmrhagclyk
<br />18a. EMBALMER - SIGNATURE
<br />Not Embalmed
<br />18b. LICENSE NO.
<br />l
<br />18c. DATE (Mo., Day, Yr.)
<br />September 3, 2014
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Alt Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />fro' Zip Code
<br />68801
<br />\ To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH See instructions and exam t les
<br />IL P T I. Enos, the Mtgat msvww . diseases, Mantes, or complications -ere directly caused the death. DO NOT mar Nominal events melt s cardle5 anew, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular Marlon without showing is etiology. DO NOT ABBREVIATE. Enw only one caws on • IOM. Aid.tma0M1 time N scnsry.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting a) e c k A . -D) 0 _ Res ? i I $ i t -y o RY I A ( t..t R C
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentlolly net conditions, K
<br />b) '
<br />any, loading to the cause listed i AI E. 1..4. kV% 0 JV I fk
<br />on line a. DUE TO, OR AS * ,'1 CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE 0/1.1S pe !l . ! - i 0 !v
<br />(disease or Injury that Initiated
<br />the events resulting M death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST
<br />d) CO IV 6e S / V 6 . 1 4 c ' r r3 I L Lt 2 4.
<br />18. PART B. OTHER SIGNIFICANT CONDITIONS - Conditions conbibutlng to tin death but not resuming In IM underlying cause given in PART 1.
<br />e0kONAIZY A/Zj E ley ISEF1 SE
<br />10 WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑YEs a NO
<br />20.1F FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />thin 42 days of death
<br />❑Not pregnant, but pregnant within
<br />❑ Not pregnant, but pregneM 43 days to 1 year before death
<br />DUnknown H pregnant within the past year
<br />21e. MANNER OF DEATH
<br />$latural ❑ Homicide
<br />❑ Accident ❑ Pending Investlgatlon
<br />❑ Suicide ❑ Could not be datemtlned
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />210. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AV
<br />DEATH?
<br />TO COMPLETE CAUSE OF DEATH2
<br />❑ YES ® NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />226. TIME OF INJURY
<br />m
<br />220. PLACE OF INJURY -At home, fatal, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF-INJURY - STREET & NUMBER APT. NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) Z 24a. DATE SIGNED (Mo., Day, Yr.)
<br />e• 3 ; . , �Qiy .S•
<br />ir.
<br />24b. TIME OF DEATH
<br />ig 23b. DATE SIGNED (Mo., Day, Yr.)
<br />E S , P )}- 4 ICI /''I
<br />23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Me., Day, Yr.)
<br />I l i )a. 4m E pCF >
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />u 23d. To the • .. • f my knowledge . at the lime, date and place gI Z 24e. On the basis of examination and/or Investigation, In my opinion death occurred
<br />u
<br />W and .. ac • cau - (s) s � J715e) .� s r 77 at the time, date and place and due to the cause(*) Meted. (Signature and 7111e)
<br />12 N gu
<br />25. WD TOBACCO USE CONTIQLB, (UTE T THE DEAn(? _
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />-claws ORGAN OR 713805 DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />201. WAS CONSENT GRANTED?
<br />Not Applicable B 28a Is NO ❑ YES ® No
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or PAM)
<br />blank SA z- ,M.b. VPr me. 3a0 j J. aebrA6 wet. t , CRAtv6 JS«IWS , I`(rXiC,iC 011)a
<br />2,8a. REGISTRAR'S SIGNATURE
<br />_ �.�.
<br />28b. DATE FILED BY$F�Ji3TRAR.(Mo, Yr.)
<br />C �J�L C PP 7 11 i8 LL i8 /r 221144
<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 OFH -IEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITALNWP51 S.
<br />DATE OF ISSUANCE
<br />09/16/2014
<br />LINCOLN, NEBRASKA
<br />20 1500557
<br />ASSfST.ANt :TAT E REFIT! I R
<br />©EPAR �MENOf HEALTF, 41 NO
<br />MtJMA S E �` r^
<br />•
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SE t'GE r ,; • e
<br />ne�TIfIPATG r r1CAT41
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