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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH.,AA147 MAif$ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,Q&PA rAilElyrQPHEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQRV4IAL`l.EcOROSI
<br />DATE OF ISSUANCE
<br />06/22/2015
<br />LINCOLN, NEBRASKA
<br />202202720
<br />202108859
<br />STANLEY 5. COOPER •
<br />' ASSISTANT STATE REGISTRAR'
<br />DEPARTMENT OF HEALTN;AND
<br />HUMAN SERVICES •
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />15 241.3
<br />1. DECEDENr3-NAME (First, Middle, Last, Suffix) • •• • •
<br />Margaret Ruth Konen
<br />FL
<br />p
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo.,DeyVr.)
<br />June 11, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />5b. UNDER 1 YEAR
<br />Se. UNDER 1 DAY
<br />B. OATE OF BIRTH (Mo., Day, Yr.)
<br />Cokedale, Colorado
<br />(Yrs.)
<br />85
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />February 21, 1930
<br />7. SOCIAL SECURITY NUMBER
<br />Be. PLACE OF DEATH
<br />HOSPITAL: 0 L.Howlett Inpatient =ELM Nursing HomeILTC 0 HoFacflty
<br />507-30-7692
<br />Bb. FACILITY•NAME (If not institution, givestreet and number)
<br />0 ERlOufpatlent 0 Decedent's Home
<br />❑DOA ❑OtNNr(speeHl)
<br />Wedgewood Care Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<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 />9d. STREET AND NUMBER
<br />1203 E. 9th Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® Yes 0 No
<br />10a. MARITAL STATUS AT TIME OF DEATH tio.Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First Middle, Last, Suffix) 1 wife, give maiden name.
<br />Bemard John Konen
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Joe Reynaga
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Raquel Rosales
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, NO. or Unk.) No
<br />14a. INFORMANT• SAME
<br />Bemard John Konen
<br />146. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSmON
<br />❑Bend ❑Donatlon
<br />ODCremation ❑Entombment
<br />Diamond ❑OthaAetlseity)
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />180. UCENSE N0.
<br />180. DATE (Mo., Day, Yr.)
<br />June 12, 2015
<br />164. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. 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 />In. PART I. VAX int .asap • dta.eee, mon., or oompooroorno Ma dins., oonood ale death. 07 NOT anus emn0i swats soon se :ardlm anal.
<br />APPROXIMATE_ INTERVAL
<br />reaphMory emtl. or 'minuend Bbrd101on without showing the aaolo41. 00 NOT ABBREVIATE Elver only ono name ons dna. Add wowed area H n000rm ry.
<br />IMMEDIATE CAUSE:,
<br />IMMEDIATE CAUSE (Final A. D 1r3
<br />disease or condition resulting a) {••• �1 `� � i•f'
<br />In death) ��1
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF: ;onset to death
<br />u
<br />Sequentially list conditions, H I
<br />any, leading to the cause listed b) r
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />onset to death
<br />(disease or injury Mat Initiated
<br />the events suiting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />4)
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT COMMONS -Conditions contributing to the death but not resulting In the underlying cause given M PART I.
<br />W
<br />Mu.\ -14 PCps4L,-(a W,1e JG CJI, t VAIN 1- c r:ALS
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑YES yr/NO
<br />20.
<br />IF FEMALE:
<br />t pregnant within past year
<br />y21�8.- MANNER OF DEATH
<br />GST Natural 0 Homicide
<br />210. IF TRANSPORTATION U1 RY
<br />0 DNvedOperator
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 VES NO❑
<br />ONO
<br />❑
<br />❑Unknown
<br />repnent at time of death
<br />pregnant, but pregnant within 42 days of death
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />0 pregnant within the past year
<br />L�J}Accdsnt 0 Pending Invastlgatbn
<br />0 Suicide 0 Could not be determined
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Speclty)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 N
<br />Pl^
<br />•
<br />22a. DATE OF INJURY (Mo., Day. Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY•At home, farm, street, factory, office building, consbuetion site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />O YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />220. LOCATION OF INJURY - STREET & NUMBER. APT. NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />\etr� ��
<br />Z
<br />a UaaLE z�
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />240. TIME OF DEATH
<br />m
<br />F it
<br />23b. QI\ATESIGNED D (( tMo., Day, Yr.)
<br />_ �
<br />230. ITN@ of DEATH
<br />/� M
<br />000(0a a
<br />S 5�
<br />iii
<br />Sao
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24e. TIME PRONOUNCED DEAD
<br />m
<br />\ V)
<br />tl 6 I
<br />23d. To ti bat of my knovdedge, 4:d/: eeeuned at Hw lime, tlate and piece W
<br />g p and due to Ms gwe(s) slated, (Sl�gna^tun and TSIe) O 1 _�
<br />Iglu
<br />11�•�Q.`// II\�,�pa�`/,._-l!x�t�11.)
<br />24e. On ted baste of exemlnatIon and/or hweetigation, In my opinion death ecCunsd
<br />et Me time, dots and plass and due to the cause(s) stated. (Signature end Too
<br />`�-- , Y \t•• Ub
<br />25. DID TOBACCO USE CONTRIBUTE TO DEATH?
<br />0 YES tie 0 PROBABLY 0 UNKNOWN
<br />29e. HAS ORGAN ORN BEEN CONSIDERED?
<br />0 YES 0 r er
<br />290. WAS CONSENT GRANTED?
<br />Not Applicable H 26a le NO 0 YES d/0
<br />27. NA/T�T,LEAND OF CERTIFeR I» or PAM) 729 N Custer Gr . r d . land • - 603t,,
<br />,ADDRESS
<br />28e. REGISTRAR'S SIONATURE
<br />fir•
<br />280. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JUN 18 2015
<br />
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