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<br />STATE OF NEBRASKA ------~
<br />;~
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH,'-AfUH 1w6rN,lA{V SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR,4~7C,~ +,Q,~AI~'fM~lilT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FD1{y7t ~r1~x, ldECOR~5.
<br />DATE OF ISSUANCE ,~~~~dh ~r,
<br />FEB 19 2049 ' s'r'-~r~.~Y,sy cb~~R~
<br />AS~ISr,~~7~ ~~ i2EGl~rftAE2
<br />D~Piil~'. d1~~Lri=r Ar~b
<br />LINCOLN, NEBRASKA 2~ 0 9 O 9 8 3 7 ~f~i~4/1~ ~~RV3CE'~- ,`.,' ,~
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<br />STATE OFNEBRASKA- dEpARTMENT OF WEALTH AND HUMAN SERVICES FINANCEAfd,~SUP~CIf;O'1~•~ : ~j ~ ~ G
<br />CERTIFICATE OF DEATH U G U
<br />1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH(Mo.,DayYr)
<br />-Gerald..-,_,.,.,. Euaone Mannin 8'obrua 11, 2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•Last Birthday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY e. DATE OF BIRTH (Mo., Day, Yr,)
<br />(Yrs.) MOS. DAYS HOURS MIN3.
<br />_Gentx'al City, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />66 ~ ..~-~
<br />ea. PLACE OF DEATH
<br />IiR5PJ7AL: ~ Inpatient
<br />October 29, 1942
<br />B6. FACILITY•NAME (II not Institution, give street and nuni6er)
<br />3t. Fraacia Medical Cantor
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />9a. RESIDENCE•STATE ~ gb, COUNTY
<br />9d.5TREETANDNUMeER
<br />Q Nursing Home/LTC ^ Hospice Facility
<br />^ ER,'UUtpatiar,: .,. Docrdanl'a riG:na - ..~ ~ .. -.,;,.,;,,r„ry,~
<br />^ COA ^ Other (SpeCIN)
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />9c. CITY CR TCWN
<br />ge.APT.NO 9f. ZIP CODE Bg.INSIDECITYLIMITS
<br />f,RRfIR 1~1 YES ^ NO
<br />109. MARITAL STATUS ATTIME OF DEATHMarried ^ Navar Married 106. NAME OF SPgUSE (FIreL Middle, Lasl, Sulflx) If wife, give maiden nem9.
<br />^ Marrl9d, but separated ^ Wltlowetl ^ Divorced ^ Unknown $harOn J. Drak®
<br />11. FATHER'S•NAME (Flret, Middle, Last, Sufflz) 12. MOTHER'S-NAME (First, .Middle, Malden Surname)
<br />13. EVER IN U. S. ARMED FORCES? GIV9 dates of service It yea. 14a.INFORMANT-NAME 14n. RELATIONSHIP TO pECEpENT
<br />(vea,no,orunk.) 0~ 2g~1960-1p 25 1 63 $ ron J. Mannin Nifo
<br />15. METHOOOF DISPOSITION 76s. EMBALMER-SI ATURE 186. LICENS tip/, 18c. DATE (Mc., Dey, Vr. )
<br />~Burlal ^ Donation ~ L ~ /!J 4
<br />^ Cremation ^ Entombment 18d. CEME RY, CREMATORY OR OTHER LOCATION CITY //TOWN STATE
<br />^Removal ^otner(spactty) Noatlalsm Memorial Park Cllamota
<br />ry, Grand Island, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (SIre96 City orTCwn, State) 176. TIp Code
<br />tCleino Funeral Homo 3213 4P North Front St. Grand Ialar4d, NE 68803
<br />ra7xel~nni.nirtnmari n,r®c
<br />18. PART I. Enter the Chain °f ev~t$••dlseasae, Injuries, or complloatlona--that dlreotly oauped the death. 00 NOT en!er tRrrn;nal avent9 Such e3 cR•diac a~resr, ~.APRROXIgggTE INTERVAL
<br />respiratory arrest, or ventricular tlprlllation without showing the etiology. DO NqT ABBREVIATE. Enter only one cause on a Ilne. Add additional I mes if necessary. I
<br />IMMEDIATE CAUSE: I onset to death
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<br />la) ` CLIP ~~ I y
<br />I L `tom
<br />IMMEDIATE CAUSE(Flnal
<br />dhraeeorcondlllonresul8ng pUETO,ORASACONSEQUENCEOF;
<br />I Onset to d
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<br />In de9tl1) ea
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<br />~re~~-. . ~~.. 1 ~`/KJr
<br />Sequantlallylletcolldltlom,tt (bl '°" `~•l~~`~°" I ~y
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<br />any, leading lO the Cause listed -_..... ~
<br />DUE T0, qR A5 A CONSEgUENCE OF:~
<br />on Ilne a. I ..
<br />I onset to death
<br />ErdertlreUNDERLYWGCAUBE i
<br />(dlaeasearln)urythetlnltlated (c)
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<br />DUE TO, OR AS A CONSEgUENCE OF:
<br />IASF . .._
<br />I onset tD death
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<br />1 B. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions coNrl6uting to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />~r(,~,~ylrti %,pytAA~+ Q ' ~ , f,~/Lrp~ ~~ ~ r (,~ /Q t ~ ~Y qR CORONER CONTACTEp9
<br />
<br />20. IF FEMALE: 21a.MANNEROFDEATH 216. IFTRANSPORTATIONINJURY 21c.WASANAUTOPSYPERFORMED7
<br />^ Not pregnant wlthln peat year ~ Natural ^ Homicide ^ DdvedOperata
<br />
<br />^Pe6senger
<br />^ Pregnant at time CI death ^ Accident^ Pending Investigation
<br />^ YES @J NO
<br />^ Not pregnant, but pregnant wlthln 42 days at death ^ Peda9trlen
<br />^ Suicide ^ Could not be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />^Notpregnant,butpregnant43deystCtyearb9loretleath ^Other(5pacity) CDMPLETECAU5EOFDEATH7
<br />^ Unknown ii pregnant wlthln the past year ^ YES ^ NO
<br />
<br />_.
<br />22e. GATE OF INJURY (Mo., Dey, Yr.) 22b. TIME DF INJURY 22c. PLACE OF INJURY•At home, larm, street, factory, olllce building,
<br />~
<br />~ canstructlon site, etc. (Specify)
<br />_
<br />__
<br />22d.INJURY AT WORK? 220. DESCRIBE HOW IN. ~ v Mf`i m ~~~
<br />^VES ^ NO
<br />22LLOCATIONOFINJURV•STREETBNUMBER,APT.NO. CfTY/TOWN STALE ZIP CODE
<br /> 23a.DATEOFDEATH (MO.,Day,Vr.) = 24a.DATESIGNEp (Mo.,Dey,Yr.) 24D.TIMEOFDEATH
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<br />a 23b. BATE SIGNED (Mo., Day, Yc)
<br />~-IZ-o`1 23c.TIME OF DEAT~~~
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<br />~ 24c. PRONOUNCEb DEAD (Mo., Dey, Yr.) 24d. TIME PRONOUNCED DEAp
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<br />and due to the cause(s) stated. (Signature and Title) ~ r+
<br />.~ ~ p 249.On the Daeia of ezaminetlon and/or investigation, In my opinion death ocCUrced at
<br />the time
<br />date and place and due tD the cause(s) stated
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<br />25. DIG TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE pONATION BEEN CONSIDERED? 2Ab. WA8 CONSENT GRANTED?
<br />^ YES C1~,.N0 ^ PROBABLY ^ UNKNOWN ^ YES [O~rVD Ndl Applicable I128a IB NO ^VES ,~NO
<br />_
<br />' ~ ~ 27, NAME, TITLE AND ADDRESS bF CERTIFIER (PHYSICIAN, CORDNER'S PHYSICIAN DR COUNTY ATTORNEY) (Type or Prlnq
<br />Anne K. Morse MD 729 N Custer' Ave., Grand Island NE 68803
<br />2Ae. REpISTRAR'S SIGNATURE 2Ab. DATE FILEp BY REGISTRAR (MO., Day, Yr.)
<br /> !~ ,( ~. FEB 17 2009
<br />HHS-61 11/03 (55061)
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