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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Robert Louis Mettenbrink Sr 2. SEX ' I 'r Male ° 5 '' - 3.-DATE-OF DEATH (M6 °; Day, Yr.) November 1 ; - 2009 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 85 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OP BIRTH (Mo., Day, Yr.) January 23, 1924 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -48 -1064 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) St. Francis Memorial Health Center LTC ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER ,. 270 E. One -R-Road 9e. APT. NO. I 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name May L Simonson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Charles Ernest Mettenbrink 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Carolina Fischer 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME May L Mettenbrink 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Daniel D Naranjo 16b. LICENSE NO. 1071 16c. DATE (Mo., Day, Yr.) November 21, 2009 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) I To be completed by: CERTIFIER 1 18. PART I. Enter the chain of events- - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 1 Year respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Faiiure To Thrive disease or condition resulting i n death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Bladder Cancer /transitional Cell More Than 2 Years any, leading to the cause listed line on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the d b not resulting In the underlying cause given In PART I. )iabetes,coronary disease,pad,osteoarthritis 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES [g] NO IF FEMALE: Not pregnant within past year 7 P regnant at time of death 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 0 Investigation ❑ Suicide 0 COM not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) November 18, 2009 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) November 18, 2009 23c. TIME OF DEATH 02:00 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Ryan D. Crouch, DO 24e. On the basis of examination and/or investig tion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES 0 NO Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, Ryan D. Crouch, DO, 800 N Alpha Street, Grand HYSICIAN ASSISTANT , CORONER'S PHYSICIAN OR COUNTY A ORNEY) (Type or Print) Island, Nebraska, .:: 128a REGISTRAR'S SIGNATURE /lam A_ f`J ( � � V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I November 19, 2009 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT., OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL.,REcQ�2D,S DATE OF ISSUANCE 11/23/2009 LINCOLN, NEBRASKA STATE OF NEBRASKA 201704282 201001802 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICO CERTIFICATE OF DEATH Exhibit "A" STAmVL j" 5. COOPER ASSISTANT STATE 'REGISTRAR DEPARTMENT r bF IYEA'LTM AND. HUMAN SERVICES 0,,9 02673