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WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AA049 I.4N SERWCES
<br />SYSTEM, IT CERnFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL �C-gRD OK FIRE _WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATit" SECTKIN, ItHC�`di /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />���IL.lF31iLEY S CO - =
<br />LINO OLN, NEBRAOSOK4 2 0 0 0 0 8 5 5 IALTHAANft 4UZANT SERVICES SLIt
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SftMES FINANGt'AN5tUPPORT
<br />VITAL STATISTICS
<br />CFRTIFICATF. OF nFATFi -
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2, SEX
<br />i a
<br />Mary Emilie Mettenbrink
<br />Female
<br />tember 26, 2000
<br />4. CITY AND STATE OF BIRTH tll not in USA.. name country!
<br />21 c. CEMETERY OR CREMATORY NAME
<br />5a. AGE Last BOhday
<br />UNDER 1 YEAR
<br />UNDER I
<br />46.
<br />DATE OF BIRTH lMonM Dav Years
<br />5b MOS I DAYS
<br />5c. HOURS
<br />Bellwood, Nebraska
<br />IYrsi 88
<br />b
<br />>
<br />7 SOCIAL SECURTIY NUMBER
<br />M CA
<br />n =
<br />8a. PLACE OF DEATH
<br />G
<br />G
<br />ca en
<br />O -1
<br />C=)
<br />rn
<br />❑Cremation ❑Donation
<br />26e INJURY AT WORK
<br />❑ ER
<br />Outpatient ❑ Residence
<br />CD
<br />z
<br />(V
<br />°
<br />,
<br />-'•
<br />Bc CITY TOWN OR LOCATION OF DEATH
<br />68803 -4050
<br />Btl INSIDE CITY LIMITS
<br />M
<br />Grand Island
<br />Ibl. AND (cll
<br />Yes 0 No ❑
<br />Hall
<br />?�
<br />9b COUNTY
<br />September 26, 2000
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER tlncludirtg Zip Code!
<br />CD
<br />0
<br />C)
<br />°
<br />Hall
<br />s
<br />Grand Islalid
<br />214 Piper Street 68803
<br />1 Yes © ND ❑
<br />10. RACE - (e.g., White. Black. Indian.
<br />11. ANCESTRY leg Italian. Mexican. German, etc)
<br />12. ❑ MARRIED
<br />® WIDOWED
<br />oC G
<br />Zcan
<br />etc I (Specify)
<br />i t e
<br />ISpeatyl
<br />Flemish
<br />NEVER
<br />MARRIED
<br />3
<br />-,V
<br />O
<br />c
<br />Q
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even it retired!
<br />Homemaker
<br />M
<br />28e On the basis of examination antl or Invesngat On, in my opinion aealh occurred at
<br />rr-
<br />C_n
<br />ro
<br />17 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Emiel NMN
<br />Bonne
<br />(Signature and Tlllel V_
<br />Emilie NMN Pieters
<br />18 WAS DECEASED
<br />EVER IN U S. ARMED FORCES
<br />cam,
<br />19a INFORMANT - NAME
<br />❑ YES ❑ NO IQ UNKNOWN 7a
<br />(Yes. no or unk I
<br />III yes give war and dates of services)
<br />m
<br />crl
<br />No
<br />Jean Wenzl
<br />ca
<br />W
<br />Q
<br />Q
<br />Recorder's Memo:
<br />The W%SW% and the W %SE% and
<br />the SWY4NEY;
<br />and the
<br />S%NW% and the
<br />E%NW%NW2A of
<br />Section
<br />16, Township 12 North, Range
<br />9 West of
<br />the 6th
<br />P.M., Hall County,
<br />Nebraska.
<br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AA049 I.4N SERWCES
<br />SYSTEM, IT CERnFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL �C-gRD OK FIRE _WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATit" SECTKIN, ItHC�`di /S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />���IL.lF31iLEY S CO - =
<br />LINO OLN, NEBRAOSOK4 2 0 0 0 0 8 5 5 IALTHAANft 4UZANT SERVICES SLIt
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SftMES FINANGt'AN5tUPPORT
<br />VITAL STATISTICS
<br />CFRTIFICATF. OF nFATFi -
<br />1. DECEDENT -NAME FIRST MIDDLE LAST
<br />2, SEX
<br />DATE OF DEATH /Month. Day ✓ead
<br />Mary Emilie Mettenbrink
<br />Female
<br />tember 26, 2000
<br />4. CITY AND STATE OF BIRTH tll not in USA.. name country!
<br />21 c. CEMETERY OR CREMATORY NAME
<br />5a. AGE Last BOhday
<br />UNDER 1 YEAR
<br />UNDER I
<br />46.
<br />DATE OF BIRTH lMonM Dav Years
<br />5b MOS I DAYS
<br />5c. HOURS
<br />Bellwood, Nebraska
<br />IYrsi 88
<br />January 31, 1912
<br />7 SOCIAL SECURTIY NUMBER
<br />22a. FUNERAL HOME -NAME
<br />8a. PLACE OF DEATH
<br />--
<br />508 -52 -1097
<br />Livingston - Sondermann F.H.
<br />v Nursing Home
<br />HOSPITAL: ❑
<br />Inpatient
<br />OTHER X - - - -- --
<br />❑Cremation ❑Donation
<br />26e INJURY AT WORK
<br />❑ ER
<br />Outpatient ❑ Residence
<br />fib. FACILITY - Name /If not institution, give street and number)
<br />Edgewood Vista
<br />o8ice budding. etc I ontyI
<br />❑ DOA ❑ Other ISpecdyi
<br />Bc CITY TOWN OR LOCATION OF DEATH
<br />68803 -4050
<br />Btl INSIDE CITY LIMITS
<br />ee. COUNTY OF DEATH
<br />Grand Island
<br />Ibl. AND (cll
<br />Yes 0 No ❑
<br />Hall
<br />9a. RESIDENCE -STATE
<br />9b COUNTY
<br />September 26, 2000
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER tlncludirtg Zip Code!
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />s
<br />Grand Islalid
<br />214 Piper Street 68803
<br />1 Yes © ND ❑
<br />10. RACE - (e.g., White. Black. Indian.
<br />11. ANCESTRY leg Italian. Mexican. German, etc)
<br />12. ❑ MARRIED
<br />® WIDOWED
<br />13 NAME OF SPOUSE tll wile. give maiden name/
<br />Zcan
<br />etc I (Specify)
<br />i t e
<br />ISpeatyl
<br />Flemish
<br />NEVER
<br />MARRIED
<br />DIVORCED
<br />- --
<br />14a. USUAL OCCUPATION tGrve kind of work done during most
<br />14b KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of working life, even it retired!
<br />Homemaker
<br />Domestic
<br />28e On the basis of examination antl or Invesngat On, in my opinion aealh occurred at
<br />Elementary or Secondary (0 -121 College 11 -4 or 5 - i
<br />8th grade
<br />16 FATHER - NAME FIRST MIDDLE
<br />LAST
<br />17 MOTHER
<br />FIRST MIDDLE MAIDEN SURNAME
<br />Emiel NMN
<br />Bonne
<br />(Signature and Tlllel V_
<br />Emilie NMN Pieters
<br />18 WAS DECEASED
<br />EVER IN U S. ARMED FORCES
<br />HAS ORGAN O 1 TI SUE DONATION BEEN CONSIDERED?
<br />19a INFORMANT - NAME
<br />❑ YES ❑ NO IQ UNKNOWN 7a
<br />(Yes. no or unk I
<br />III yes give war and dates of services)
<br />No
<br />Jean Wenzl
<br />2403 W. 14th, Grand Island,
<br />Nebraska 68803
<br />AUTOPSY
<br />20 ALMER - SIGNATURE 8 LICENSE NO
<br />PREGNANCY
<br />II
<br />21a. METHOD OF DISPOSITION
<br />21 b. DATE
<br />21 c. CEMETERY OR CREMATORY NAME
<br />�•
<br />(Ages 10 -541 Yes NO
<br />Yes Na
<br />Ves NO
<br />Memorial Park
<br />//43
<br />26c HOUR OF INJURY
<br />Burial Removal
<br />® ❑
<br />September 29,2
<br />OOestlawn
<br />22a. FUNERAL HOME -NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston - Sondermann F.H.
<br />❑Cremation ❑Donation
<br />26e INJURY AT WORK
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR FI F.0 NO CITY OR TOWN.
<br />STATE, ZIP)
<br />yes No ❑
<br />o8ice budding. etc I ontyI
<br />601 North Webb Yad, Grand Island,
<br />Nebraska
<br />68803 -4050
<br />IMMEDIATE C E
<br />-PART
<br />fENTER�A ONE CAUSE PER
<br />Ibl. AND (cll
<br />Interval between onset ano tem a
<br />�-1
<br />i
<br />286 TIME OF DEATH
<br />September 26, 2000
<br />DUE TO, OR AS A CONSEOUE E OF
<br />Interval berCee onset ann nPmn
<br />(b
<br />s
<br />DUE TO OR AS A CONSEQUENCE OF
<br />TIME OF DEATH
<br />28c. PRONOUNCED DEAD tA4o_ Day. Yr./
<br />Interval between onset ano ilea,
<br />Icl
<br />September 27, 2
<br />0 6:52AM
<br />,A
<br />OTHER SIGNIFICANT CONDfTIONS Conditions contributing to the death but not related PART
<br />PART
<br />111 IF FEMALE. WAS THERE A
<br />AUTOPSY
<br />.WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />II
<br />IN THE PAST 3 MONTHS'
<br />EXAMINER OR CORONER
<br />(Ages 10 -541 Yes NO
<br />Yes Na
<br />Ves NO
<br />26.
<br />261, DATE OF INJURY lMO Day Yr)
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />[] A,cc�dent [:] Undeterm,ned
<br />M
<br />Suicide LJ Pend -rig
<br />E]
<br />26e INJURY AT WORK
<br />251 PLACE OF INJURY - At home, farm. street. lactmy
<br />26g LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE
<br />Homicide InveSligal,nn
<br />❑❑
<br />yes No ❑
<br />o8ice budding. etc I ontyI
<br />a. DATE OF DEATH tMO. Day Yr.)
<br />28a DATE SIGNED /MO. Day W.1
<br />286 TIME OF DEATH
<br />September 26, 2000
<br />a=
<br />s
<br />'�b. DATE SIGNED (MO.. Oay. Y0
<br />TIME OF DEATH
<br />28c. PRONOUNCED DEAD tA4o_ Day. Yr./
<br />28d. PRONOUNCED DEAD /Hours
<br />J
<br />sI�
<br />September 27, 2
<br />0 6:52AM
<br />Qz
<br />g °c
<br />M
<br />� A To the best of my knowledge death occurred at the h e. date and Dine and due t0 the
<br />J(
<br />28e On the basis of examination antl or Invesngat On, in my opinion aealh occurred at
<br />° ¢ °
<br />°>
<br />causels� statetl.
<br />Z� ,
<br />c 5
<br />the time. date and place and due to the cause(sl stated,
<br />(Signature and Tlllel V_
<br />(Si nature and Title
<br />DID TOBACCO USE CONTRIBUTE 70 THE DEATH'
<br />HAS ORGAN O 1 TI SUE DONATION BEEN CONSIDERED?
<br />aB'b WAS CONSENT GRANTED'
<br />❑ YES ❑ NO IQ UNKNOWN 7a
<br />❑ YES NO
<br />/� ❑ YES ❑ NO
<br />` William J Landis, MD, 2444 1 FaidlfiW Grand Island NE 68803
<br />32a REGISTRAR 32b. DATE FILED BY REGISTRAR tMo.. Day Yr./
<br />OCT 2 20 00
<br />��O
<br />
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