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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H54t6'
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE N.,EB,
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITQRYVR
<br />DATE OF ISSUANCE
<br />06/22/2015
<br />LINCOLN, NEBRASKA
<br />20218859
<br />ES, IT CERTIFIES
<br />TH AND
<br />•STANLEY SCCOPER
<br />,f
<br />►" 1ASSISTANTSTATE RE4.3110 ,1
<br />k EPAR7MENT, OF HEAL79t,
<br />'HUMAN SERVICES : c•-• ..
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<br />STATE OF NEBRASKA . DEPARTMENT OF HEALTH AND HUMAN SERVKCES'15-2410
<br />CERTIFICATE OF DEATH
<br />1. DeCEOENTS4IAME (PtraL Middle, Last, Suffix)
<br />Margaret Ruth Konen
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo.Dy,Yr,)
<br />June 11, 2015
<br />♦
<br />CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />Cokedale, Colorado
<br />5s. AGE -Last Birthday
<br />(Yrs.)
<br />85
<br />Ob. UNDER 1 TEAR
<br />Se. UNDER 1 DAY
<br />MOs.
<br />DAYS
<br />HOMO
<br />MINS.
<br />S. DATE OF BIRTH (Mo.. Dy. Yr.)
<br />February21, 1930
<br />7. SOCIAL SECUIUTY NUMBER
<br />507-30-7692
<br />a. FACILITY -NAME (If not Institution, give street and number)
<br />Wedgewood Care Center
<br />a. PLACE OF DEATH
<br />1!AL; ❑ Inpawnt
<br />❑ ERIOulpadent
<br />❑ DOA
<br />Qnge;®Nwsag HpnefLTC ❑Hoopla Facility
<br />❑ Decedent% Homs
<br />❑ OtnIMEMcIfy)
<br />Sc. CRY DR TOWN OP DEATH (rlahrde Zip Cede)
<br />Grand Island 68803
<br />M. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />M. COUNTY
<br />Hall
<br />00. CITY OR TOWN
<br />Grand Island
<br />Od. STREET AND NUMBER
<br />1203 E. 9th Street
<br />N. APT. N0.
<br />IN. ZIP CODE
<br />68801
<br />Ihg. INSIDE env UMITs
<br />®YM 0 No
<br />101. MARITAL STATUS AT TIME OF DEATH ®.Marded 0 Never Married
<br />❑ Marred. but separated 0 W Wawsd 0 DMaaad ❑ Unknown
<br />100. NAME OF SPOUSE (First, Middle. Last, Willa) H will, OW =Won name.
<br />Bemard John Konen
<br />11. FATHER'LNAME (First. Middle, Last, soh)
<br />Joe Revnaga
<br />12. MOTHER'Bd1AME (First, Middle, Mahan Surname)
<br />Raquel Rosales
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service N Yee.
<br />(Yea, No. or Unk.) No
<br />141. INFORMANT -NAME
<br />Bemard John Konen
<br />140. RELATIONSHIP TO oaCEoeNT
<br />Husband
<br />16. METHOD OF DISPOSION
<br />❑twmw ❑Don.eo..
<br />ad Cremation ❑EntmwreM
<br />0MmoM 0c11wt.P.Atfy)
<br />101. EMBALMERMIONATURE
<br />Not Embalmed
<br />10b. LICENSE NO.
<br />100. DATE (Mo., Dy, Yr.)
<br />June 12, 2015
<br />10d. 0EM57TRY, CREMATORY OR OTHER LOCATION CITWTOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Slab)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />170. Zip Coda
<br />68801
<br />P
<br />CAUSE OF DEATH (Se. Instructions and examples)
<br />IL PART L aperw eak'a(�•dMm..w,0501, ser w,pJirs..m mg dim.* .e..4w DO 110T .Peen wo.G..T..wne .cob as emdiw
<br />,..p11 Dory l5.. ser v mmeuler swam. TAhee woa.Rsw ANwq. DO ROT ANRMATL anter only ono woe on. Nob Ase addMe1r Wer It nwAomy.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />M death)
<br />Sequentially Int conditions, N
<br />any, lading to the Souse Meted
<br />en Mea.
<br />1) t\-.,ivem.%Ne.: t ueASe
<br />DUE T0, OR AS A CONSEQUENCE OF:
<br />b1
<br />' APPROXIMATE INTERVAL
<br />onsetl'tto Muer
<br />onset ts dant
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE a)
<br />(disease or Injury that Initiated
<br />the events resulting In MMR) DUE TO, 0R AS A CONSEQUENCE OF:
<br />LAST
<br />4)
<br />onset to *MA
<br />onset to death
<br />10. PART S. OTHER SIGNIFICANT CONDITIONS -Conditions eoMr/utbq be Um dnth but not neultbq In the underlying cease. given M PART
<br />1,AvAtol,e. 1 C e$ ..&.4t W.w J 7 CVT , l \ 1.1 `r 1 {J Q. '!c {r
<br />20. IF FEMAL : 21e. MANNER OF DEATH 21b. IF TRANSPORTATION
<br />pregnant within past year
<br />Mitt at Una of death
<br />❑ Not pregnant, but pregnant within 42 days at death
<br />❑Not pregnant. but pregnant 43 Nye to 1 year before death
<br />❑Unknown If pngaM within tit pat year
<br />$Holum ❑ Homicide❑ Drlveri0paralar
<br />0
<br />ACCWeM 0 Pending InvasegaticnPassenger
<br />0 Suicide 0 Could not be determined 0 Pedestrian
<br />0 prier (Specify)
<br />11. WAS MEDICAL EXAMINER
<br />ORCORONER
<br />CONTACTED?
<br />❑
<br />YES 14 410
<br />21a. WAS AN AUTO►ny,PERPORMED?
<br />❑ vas
<br />y�/No
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />Oyes Ow
<br />Vr
<br />220. DATE OF INJURY (Mo., Dy. Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY•At hams, ?arm, street. factory, 'Rica building, combustion site, etc. (Specify)
<br />22d. INJURY AT WORN?
<br />0Yes 0 s
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />220. LOCATION OF INJURY • STREET $ NUMBER. APT. NO.
<br />STATE ?A CODE
<br />Elig
<br />121
<br />25.
<br />23s. DATE OF DEATH (Mo., Day. Yr.)
<br />(ctl-S
<br />23b.ATE memo (Mo., Day, Yr.)
<br />230. TIME OP DEATH
<br />23(1. To the bat of My knowledge, Meth 0000014 at the 1611, MSM and pace
<br />and der to the epum(*) Natal. (mgnatun The)
<br />VYN
<br />DID TOBACCO USE CONTRIBUTE TO ?TIE DEATH?
<br />YES bkr0 ❑ PROBABLY ❑ U*01OWN
<br />24a. DATE SIGNED (Mo., Dy, Yr.)
<br />20.11111E OF DEATH
<br />m
<br />200. PRONOUNCED DEAD (Mo., Day. Yr.)
<br />24d. TIME 5000101 110® DEAD
<br />m
<br />24e. On Um bask' at examM tion *MIA ImssSgatloo, in my opinion Maar eawnd
<br />at the time, dab end place and der to the cause(s) MOM (SISMlum seg TWO
<br />2a. HAS ORGAN OR TM8US_QONATNIN BEEN CONSIDERED?
<br />❑ vas 1�/ NO
<br />Zee. WAS 0011850.7 MINTED'?
<br />Not Applicable N 2nd le NO 0 YES I0.0
<br />27•NAM+E�EAND AMRESS cER^FeR a Fes) 729 N Custer Ave.
<br />144,7 6"/
<br />2nd. REGISTRAR'S SIGNATURE
<br />tab. DATE FILED BY REGISTRAR (Me.. Day, Yr.) I
<br />JUN 18 2015
<br />
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