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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE13RASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITARY FOR VIT,4LARE~(~ Q)S, S DATE OF ISSUANCE S.T.ANLE5. COOF?ER 11/23/2009 201001802 ASSIS.T,4NT STAT 'PFGISTRAR DE'PAF`~"Tl1ei •tr F ~YE,St'jLThl AND. LINCOLN, NEBRASKA 'HU X,& $ERI!IC ,fir t STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICEga ^,f r 0267.3 CERTIFICATE OF DEATH ` 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2, SEX ) •3.•DA R •QPIJEAT (MMp vay,,.YYr.) Robert Louis Mettenbrink Sr Male - r 'C?Novembe6 , 009 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH $a. AGE -Last Birthday Ph. UNDER 1 YEAR 5c. UNDER 1 DAY ^ "6: DATE Of-BIRTH (Mo., Day, Yr,) (Yrs.) MOS. DAYS HOURS MINE. Grand Island, Nebraska 85 January23, 1924 7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH 508-48-1064 HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY-NAME (if not Institution, give street and number) ❑ ER/Outpatient ❑ Decedent's Home lY St. Francis Memorial Health Center LTC ❑ DOA ❑ Other (Specify) LU Sc. CITY OR TOWN OF DEATH (include Zip Code) 8d. COUNTY OF DEATH o Grand Island 68803 Hall 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN LU Nebraska Hall Grand Island :D 9d. STREET AND NUMBER r I I 98. APT. NO. 9f. ZIP CODE 9. INSIDE CITY LIMITS g 270 E. One-R-Road 68803 YES ® NO 2-1 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b, NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name !E ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown May L Simonson d 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname) 2 Charles Ernest Mettenbrink Carolina Fischer a 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. =Mla INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT E s (Yes, No, or unk.) NO ttenbrink W ife 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) to, ® Burial ❑ Donation Daniel D Naranjo 1071 November 21, 2009 ❑ Cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE ❑ Removal ❑ Other (Specify) Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801 CAUSE A See Instructions and exam les 18. PART I, Enter the chain of events-diseases, Injuries, or complications-that directly caused the death, 00 NOT enter terminal events such as cardiac arrest, i APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Faiiure TO Thrive ; 1 Year disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Bladder Cancer/transitional Cell More Than 2 Years any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE C) (disease or injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST fl) 18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART 1. 19. WAS MEDICAL EXAMINER Diabetes,coronary disease, pad,osteoarthritis OR CORONER CONTACTED? ❑ YES ® NO W 20. IF FEMALE: u. 210. MANNER OF DEATH 2111. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Not pregnant within past year ® Natural ❑ Homicide ❑ Driver/operator LU ❑ Pregnant at time of death ❑ Accident Pending Investigation ❑ Passenger ❑ YES ® NO © Not pregnant, but pregnant within 42 days of death ❑ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE ❑ Suicide Could not be determined •0 ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Other (Specify) TO COMPLETE CAUSE OF DEATH? i ❑ Unknown if pregnant within the past year ❑ YES ❑ NO E 22a. 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) U 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED F ❑ YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH November 18, 2009 LL 23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH 24C. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD z November 18, 2009 02:00 AM a 44 ZZ s O 23d. To the beat of my knowledge, death occurred at the time, date and play k ry O and due to the cauw(a) stated. (Signature and Title) g g 249. On 1110 basis of examination andlor investigation, in my opinion death occurred at F the time, date and place and due to the cause(s) staled. (Signature and Title) Ryan D. Crouch, DO a 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND XDDRESS OF 1,t:K1 I R( Y R COUNTY (Type or Print) Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 280. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 19, 2009