202105962 - Laserfiche WebLink

Browse

%kBAtiMD,Wi%roses ijfrr :tttyaw t . 'ttttilltCY�t6Is �s cr%rtttu. �j(Ri 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 6/21/2021 LINCOLN, NEBRASKA 202105962 r , SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 21 07908 Pursuant to section 30-2443, demands for notice which may affect tine estate of the deceased are filed with the county courtin the county where the decedent resided at the time of death. T 1. DECEDENT'S-NAMESuffix) (First, Middle, Last, - - - Rebecca; Louise Mettenbrink 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) June 11, 2021 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)' Wahoo, Nebraska (Yrs.) 66 MOS. DAYS HOURS MINS. January 4, 1955 7. SOCIAL SECURITY NUMBER 507-62-8490 8a. PLACE OF DEATH HOSPITAL Ea Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Grand Island, Regional Medical Center 0 ER/Outpatient 0 Decedent's Home 0 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 3017 Midway Road Be. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS 68803 L Ui YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 1012. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Rodger Mettenbrink 11. FATHER'S.NAME (First, Middle, Last, Suffix) Samuel Wilson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Elaine Kellet 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Rodger Mettenbrink 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION Burial 0 Donation 16a. EMBALMER -SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) June 15, 2021Ea '> Cremation 0 Entombment Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING 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) HI 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 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) Sepsis disease or condition resulting onset to death 48 Hours In death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Bed Sores On Buttocks any, leading to the causelisted on tine a. onset to death 6 Weeks DUE TO, OR AS A CONSEQUENCE OF: Enter tel UNDERLYING CAUSE c) Alcohol Abuse (disease or injury that initiated onset to death Years the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) COPD onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ©' Not pregnant within past year 0 Pregnant item* of death 21a. MANNER OF DEATH ® Natural 0 Homicide 0 Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑YES ®NO ©< Not pregnant, but pregnant within 42 days of death❑ ❑� Not pregnant. but pregnant 43 days to 1 year before death IaiP" Unknown If pregnant within the past year 0 suicide ❑could not be determined Pedestrian ❑ Other (Speedy) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22e. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a1 23a. DATE OF DEATH (Mo., Day, Yr.) June 11,2021 .8ci 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH I 1 2:J 23b. DATE SIGNED (Mo., Day, Yr.) June 14.2021 23c. TIME OF DEATH 01:31 AM a k 1 8 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD u 0 8 e iLI 23d. To the best of my knowledge, death occurred at the time, date and place end due to the cause(s) stated. (Signature and Title) Gary Settle, MD " Ie 224e. 8 18 o O On the. basis of examination and/or Investigation, in my opinion death occurred at the time, date andace pl and due to the eau se(s) stated. (Signature and Title) 25, DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ? 0 YES ❑ NO; 27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE a� T 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 17, 2021 O N' N 01 1\,)