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;;,0,\%, „Mai STATE OF NEBRASKA WHEN ! THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 RECORDS DATE OF ISSUANCE 6/16/2017 LINCOLN, NEBRASKA 18. PART]. Enter the chain of eve rts diseases, injuries, or complications -that directly caused: the death. 00 NOT enter terminal events such as cardiac arrest, 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 (Final disease or condition resulting IMMEDIATE CAUSE: a) Respiratory Failure 201801396 STATE OF NEBRASKA - DEPARTMENT OF HEALTH? AND HUMAN SERVICES CERTIFICATE OF DEATH Coor STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS - NAME (First, Middle, Last, Suffix) Ronald William Mettenbrink 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Merrick Co tihty, Nebraska 7. SOCIAL SECURITY NUMBER 508 -54 -2565 8b. FACILITY -NAME (if not Institution, give street and number) rt 0 C w IY Q J wt z. LL a w 'Q d 905 E. Phoenix Ave 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 9a, RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 905 E. Phoenix Ave 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO 15. METHOD OF DISPOSITION ® Burial 0 Donation ❑ Cremation ❑ Entombment ❑ Rernoval <❑ Other (Specify) 6a. AGE - Last Birthday (Yrs.) 78 9b. COUNTY Hall Sb. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 16a. EMBALMER- SIGNATURE Katie M. Smydra HOURS 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY MINS. OTHER ❑ Nursing Home /LTC ® Decedent's Horne ❑ Other (Specify) 9f. ZIP CODE 68801 10b. NAME OF SPOUSE (First, < Middle, Last, Suffix) If wife, give maiden nem* ,Judith Vogel 11. FATHER'S -NAME (First, Middle, Last, Suffix) William Mettenbrink 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Rose Caroline Mader 14a. INFORMANT -NAME Judith Mettenbrink 16b. LICENSE NO. 1454 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)', All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska 3. DATE OF DEATH (Mo., Day, Yr.) June 6, 2017 6. DATE OF BIRTH (Mo., Da May 20, 1939 ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES 0 NO Wife 16c. DATE (Mo., Day, Yr.) June 10, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Wieqert Cemetery CITY /TOWN Grand Island STATE Nebraska' 17b, Zip Code 68801 CAUSE OF DEATH (See instructions, and examples) APPROXIMATEINTERVAL onset tJ death 1 Day 81 death) $equetltially list cotidltions, if any, leading to the Cause hated • on linea - - DUE TO, OR AS A CONSEQUENCE OF: b) Congestive Heart Failure onset to death 5 Years DUE TO, OR AS A CONSEQUENCE OF: c) onset to death Enter the UNDERLYING CAUSE (disease Or injury tttat mniat¢tl ngin deathl Nee events rasuitt LAST DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Myelodysplastic Syndrome 22a. DATE OF INJURY (Mo., Day, Yr.) 20. 1F FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death p Naf pregnant, but pregnant within 42 days of death ❑ Not preQnant,.bat pregnant43 days to 1 year before death ❑ 41tii hnownit ptegnam wlthttt the past year Ct. 0 2 d. (. NJURY AT WORK? YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 21a. MANNER OF DEATH IE Natural ❑ Homicide ❑ Accident ❑ Pending Investigation Suicide ❑ Could not be determined 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED CITY/TOWN 23a. DATE OFDEATH (Mo., Day, Yr.) June 6 2017 23b. DA E SIGNED'(Mo., Day, Yr.) June 9, 2017 23c. TIME OF DEATH 03:53 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) IsaaOJ. Bern, MD 25. DID: TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ENO '❑ PROBABLY ❑ UNKNOWN 26a. REGISTRAR'S SIGNATURE /j /i zr 24a. DATE SIGNED (Mo., Day, Yr.) 24d. TIME PRONOUNCE0DEAD< 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 248, PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEE CONSIDERED? ❑ YES 2 N 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 1E NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? :. ❑ YES ❑ NO STATE ZIP CODE 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 266, WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.) June 12, 2017