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STATE OF NEBRASKA -
<br />.GP46h INP_Jps;;Z:;51.9)=00.T .,;;::: o%04iNOCddDS?>°:,:; ."59la'1,llt@tr:r: •Z?.W TA,P.
<br />WHEN MIS 'COPY ;tARRI S THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />SSA `TRW CCIPi! i ;all^ ME ORIGINAL RECORD ON FILE WITH THE NEBRASKA: DEPARTMENT OF HEALTH AND
<br />LIMANSERVICES; VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />)L SARAH BOHNENKAMP'
<br />U.: L J tJt ." .7; O ;. 'A R
<br />DEPARTMENT OF HEAILTISTANT STATE HA
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE. QF .:DEATH..,
<br />t1 ES't`$mmo,,,((`Ir{t Mlddhr, Last, Suffix)
<br />;.Nle•Mat:tactt .
<br />.CITY AND S'rATE QR'' ERRITORV OIR' FOREIGN COUNTRY OF BIRTH
<br />Fr ?e)t:t; Nebraska. <>,.
<br />SECtiRI.TY:susses
<br />4,0065:
<br />66. FACILITY-NAM&pf riot Melodeon, give street and number)
<br />aood arrtal tarti: OOieIV-Grand Island Village
<br />St:. CtT! Ot 70YVN
<br />CI
<br />It RRiIDENce-STATE
<br />Nebraska °::....
<br />r. ND NtJMaER
<br />Code)
<br />9b. COUNTY
<br />Hall
<br />AT f 41E OF DEATH ® Married. ❑ Never Married
<br />{']Widowed ❑ Divorced 0 Unknown
<br />ATtlEtt!S,NAME t) rsE;: !AMOR Last, Suffix)
<br />Nltittotisert:;
<br />13 EVCRIN U.S. ARMEE . Q #CE87 dive dices of service if Yea.
<br />Ares, No, or Unit ) No
<br />1CUE'I:HOUOF 1DtSPO5r:ioN 16a. EMBALMER -SIGNATURE
<br />tau ''- .:.....::...:
<br />>, rtat''. ,:.fl4ii'attotl;; Stacie L Ruiz
<br />Cislttadon;: > Entom mint
<br />Removal QOthar(Spacttr)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />fib. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER -MAY
<br />MOS.
<br />DAYS
<br />Oa, PLACE:OFDEATH
<br />HOSPITAL :Inpatient
<br />HOURS
<br />MINS.
<br />n
<br />3. DATE OF
<br />N©v
<br />6. DATE OF
<br />OTHER ® Nursing Home/LTC
<br />0 ER/Outpatient 0 Decedent's Home
<br />Q DOA ❑ Other (SpectfyL
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand .Islatid
<br />Y4. APT. NO.
<br />9f. ZIP CODE /
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, 8uffixpf wife, give n`afden name
<br />Donald Joseph Manson
<br />L.
<br />12. MOTHER'S -NAME (First, Middle, Malden
<br />Isabel Bender
<br />14a. INFORMANT -NAME
<br />Donald Joseph Marisch
<br />16b:LICENSE NO.
<br />1+4495
<br />10d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />Grand Island City Cemetery Grand Island
<br />1ta. E°I1NE)tlt( HO*E:NAMEtND MAILING ADDRESS (Street, City or Town, State)
<br />'AU FaithsFait4c Eia teraH'(ome. 2929 S. Locust Street, Grand Island,,Nobraska
<br />loon. Oaufgop
<br />41. lift •pagditiOr.wx
<br />n
<br />18. PAR? ti DTI:TER;SIG IFICi
<br />(Hypertension '.
<br />*O1F FEAAA(E...'<:.
<br />004:90.I4?day:411
<br />��-�yy Pyegfl* 4;It l#u df d►kth
<br />[" Itoagetinara, treat pre9?dn
<br />afia.ORTE or
<br />A
<br />Otyl
<br />'DATE 9F Ott*t'
<br />Notmrnber3,_2
<br />b ,DAt ;StGNED(Mo:, Day, Yr.)
<br />�dlte pis:el . .
<br />CAUSE OF DEATH (See Instructions and examples)
<br />es, intones, oreompticatlons4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />wMlout showing the etiology. DO NOT ABBREVIATE, Enter only one WWI on..a line. Add additional Tines if necessary.
<br />DIA1`E CAUSE:
<br />Metastatic Choriocarcinome To Liver
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b).
<br />UE 1O, OR AS A CONSEQUENCE OF:
<br />UE TO, OR ABA CONSEQUENCE OF:
<br />PIONS-C
<br />hi 42 (eye of death
<br />ye to 1 year baton death
<br />year
<br />Day, Yr.)
<br />Landis,
<br />144.RS
<br />Soouse'.
<br />160. DATE
<br />No,
<br />tions contributing to the death but.notresulthly in the underlying cause/given in PART I; -
<br />21a. MANNER OF DEATH
<br />Natural Hot!tiditis :.
<br />❑ Accident 0 Pending InveMigstion
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLAOE
<br />HOW INJURY OCCURRED
<br />MEER, APT.NO. . CITY/TOWN
<br />Day; Yr.)
<br />23c. TIME OF DEATH
<br />01:29 PM
<br />daath occurred at the three, dare and place
<br />(Signature and Tide)
<br />TO THE DEATH? G
<br />ILY ® UNKNOWN
<br />TIDIER (Type or Irrint
<br />4441N; Faidtey Avenue, Grand Island, Nebraska, 68803
<br />1
<br />26a. HAS OR
<br />❑ YES
<br />21b IP TRANSPORTATION INJURY
<br />burg/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AU'
<br />❑ Yam..:'
<br />21d. WERE A
<br />TO COM
<br />© Yet
<br />F INJ4IRY-At':homei farm,.strset, factory, office building, cgnhblf
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24t . PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF
<br />24d.
<br />24e. On the buts of examination and/or Investlpatlon, in my
<br />the tang, date and place and due to the cam(*) stated.
<br />AN OR'TISSUE DONATION:'BEEN,CONSIDERED?
<br />26b. WAS CON1
<br />Not Applicable H 28 N
<br />25b. DATE FILED BY RE
<br />November 6, 201S
<br />• lc
<br />Y.
<br />
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