|
ditiva
<br />83isa D/ a tdasa gIMR6 d,'I€t `I IC;tea a NOW6kko.,iOlga AA 11
<br />STATE OF NEBRASKA �'7�s'
<br />pye '!1St( f@f381t eeY4tyetypyvea +8tt1tr/1Y[ilf/lye crr1t41rddAt�ralydr .rile 1 r fi:VM4V413ft7AY'�,i
<br />1,\. .F.3z. . u n. .w....-µ ti. .. ,a:..tee :':.s... . '
<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 />1/22/2021
<br />LINCOLN, NEBRASKA
<br />202101214
<br />A ;7
<br />L•"atoo'l j) /&A74.ar�
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />tt 3i�1efI
<br />11 01276
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. ' I
<br />1. DECEDENTS•NAME (First, Middle, Last, Suffix)
<br />Mary Conception <Mettenbrink
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 17, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />ba. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />Lexington, Nebraska
<br />(Yrs.)
<br />79
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />December 8, 1931
<br />7. SOCIAL SECURITY NUMBER
<br />505-36„9204
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC © Hospice Fatuity
<br />8b. FACILITY -NAME (1f not institution, give street and number)
<br />1920 W. 11th St.
<br />0 ER/Outpatient E Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />ac. CITY OR TOWN
<br />Grand Island
<br />OF DEATH (Include Zip Code)
<br />68801
<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 />94. STREET AND NUMBER
<br />1920 W. 11th St.
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />90. INSIDE CITY LIMITS I'
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Herb Mettenbrink
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Genera Munoz
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Filiverta Godinez
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Herb Mettenbrink
<br />14b. RELATIONSHIPTO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />16a. EMBALMER -SIGNATURE
<br />Matthew T. Myers
<br />16b. LICENSE NO.
<br />1411
<br />16c. DATE (Mo„ Day, Yr.)
<br />April 22, 2011
<br />E Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION' CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />111. PART 1. Enter the chain of events- 41 , Injuries, or compllcatlona.that directly caused the death. DO NOT entertemdnal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 11 necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE( Pinel : a)Nonsmall Cell Carcinoma Unknown Primary Site
<br />disease or conditionresu ting
<br />onset to death
<br />One Year
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially bat conditions, if b)
<br />any, Heading to the cause listed
<br />on lima.
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enta the UNDERLYING CAUSE C)
<br />(disease or Injury that initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART II, OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES E NO
<br />2O. IF FEMALE: -
<br />0 f otpregnentwhhie put year
<br />0 emanate et time ofdeath
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />'
<br />❑ YES E NO
<br />❑ Not pregnant, but pregnant within 42 days of death8uicid.Could
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown if pregnant within the past year
<br />❑ 0 not be determined
<br />0 Pedestnan
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />DYES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER 11II
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 17, 2011
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Abri) 19, 2011
<br />23c. TIME OF DEATH
<br />09:20 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />234. to the best of my knowledge, death occurred at the time, date and place
<br />and due to the meets) stated. (Signature and TSM)
<br />Donald Wirth, MD
<br />24e. On Inc basis of examination and/or investigation, in my opinion death waned at
<br />the tine, date and place and due to the cause(s) stated. (Signature and title)
<br />24. DID: TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES E NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YE$ 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Donald Wirth, MD, 2116 W Faidley #400, Box 9802,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �- I/ ��_
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 19, 2011
<br />
|