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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE 'A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />5115/2019
<br />LINCOLN, NEBRASKA
<br />20200568
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE. F DEATH
<br />1. DECEDENTSJNAME (First, Middle, Last, Suffix)
<br />Michael Richard Manthey
<br />. CITY' AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Michigan City, Indiana
<br />I 7. SOCIAL SECURITY NUMBER
<br />. 311-72-8318
<br />68.
<br />AGE - Last. BirtItlay
<br />(Yrs.)
<br />. FACILITY -NAME (If not Institution, give street and number)
<br />I CHI Health St. Francis
<br />Z�'r t:•a"' C.. 7"..'t' ::Th n,„-.cr.. , :L".p
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1004 Sherman Avenue
<br />9b. COUNTY
<br />Hall
<br />UNDER 1 YEAR
<br />MOS. DAYS
<br />61 ti
<br />8a. PLACIOF DEATH
<br />HOSPI L ❑ Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />I
<br />t . CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />8c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 6, 2019
<br />8. DATE OF BIRTH (Mo., lPay, Yr.)
<br />December 10, 1:957 -
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />lad' C')WJTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Hospice Facility
<br />9g. INSIDE CITY UMITS
<br />® YES ❑ NO
<br />lea. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Richard Manthey
<br />13: EVER IN U.S.; ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />8. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />® Cremation ❑ Entombment
<br />❑ Removal 0 Other (Specify)
<br />1Ob. NAME OF SPOUSE (First, Middle, Last,
<br />Judi ANiieda Verzal
<br />112. '.OTHER'S -NAME (First, Middle,
<br />J Helen Bolin
<br />14a. INFORMANT -NAME
<br />Judi Almeria Manthey
<br />Suffix) If wife, give maiden name
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />Maiden Sumamb)
<br />14b. it' .ATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />May $, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION.
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraskit
<br />17b. Zip<Code
<br />68801
<br />CAUSE OF DEATH (See inttructions and examples)
<br />PART I. Enter the Chain events- -diseases, injuries, or complications -that directly caused the death. DO 110T enter terminal events such as cardiac arrest,
<br />respiratory arrest. or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Zine. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Metastatic Adenocarcinoma Prostate
<br />(smelts* or condition resulting
<br />IA death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially fist condition;, M b)
<br />any, *riding 10 the cause tilted
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disease or injury eiat initiate*
<br />tits events resulting In death)
<br />APPROXIMATE INTERVAL
<br />onset to death ..
<br />5 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Vakno■m N pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />13 0 YES ❑ NO
<br />v I22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />ci
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be detenaarod
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ pedestrian
<br />other t6Pecih')
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22c. PLACE OF INJURY•At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />2e. DESCRIBE HOW INJURY OCCURRED
<br />CITY/TOWN
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />May 6,2019>
<br />Y 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />9' J May 7 2019 02.27 AM
<br />2d. To the frost of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) staled. (Signature and Title)
<br />~ Ryan©. Crouch, DO
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the causes) stated. (Signature and Tea)
<br />b. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUEDONATION BEEN CONSIDERED?
<br />❑ YES E ,�O
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR 33fGNA7tJRE C
<br />❑ YES ® NO 0 PROBABLY ❑ UNKNOWN
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES 0 NO
<br />28b. DATE FILED BY REGISTRAR I. Day, Yr.)
<br />May 13, 2019
<br />
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