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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND., I-l(�lN;4N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAQEPAI�TM NT' Ol� HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPQSITORY FOR Vl�Ri R���1@I7�� `�� ;� � 3 �
<br />�� ti • � e - r �,. � ; � ,
<br />flATE OF ISSUANCE � '�
<br />> ., . _,' ;,
<br />2 012 0 518 3 sr,�uc� 5 coo�a- �;, :�
<br />06/19/2012 ASS�''S�ANT 9,�94� R�GI�TRAR !� y p; _>
<br />DEPA�r1�N�F�k{F�47iTEf�tUVD g,: r-
<br />LINCOLAI, NEBRASKA HUM1',�41i�, �'RVICFS ,- r:, , �°'
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE� t a!- .�'.' �, ,. ,�t, r.' �,n',u� ?n�n�e
<br />CERTIFICATE OF DEATH = � � .s' • � • �"° �` , . "� `''� �`�• �
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<br />1. DECEDENTS-NAME (First, Mlddle, Last, Sutflxl 2. SEX 3l fjATE�O� QF.�CThk(�., DaY. YrJ
<br />Larry Lee Hassler Male '`- June d 4�,2U1�
<br />4. CI7Y AND STATE OR TERRITORY, OR FOREIGN CWNTRY OF BIRTH Sa. AGE • Laet Birthday b. UNDER 7 YEAR Sc. UNDER 7 DAY 8. DATH OF BIRTH (Mo, Day, Yr.)
<br />(Y�e•1 MOS. DAYS HOURS IIANB.
<br />Washington, Kansas 73 November 7,1938
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />505-46-8893 �� InpaBe� OTHER ❑ Nureing HomeILTC � Hosplce Facllity
<br />8b. PACILITY-NAME (If �rot Ir�stihrtlon, Bive street arM number) � EWOutpaUern � DecadeM's Home
<br />�
<br />� 1919 West John Street ��A ❑��s��r1
<br />c�
<br />� 8c: CIT'Y OR TOWN OF DEATN pnclude Zip Code) Bd. COUNTY OF DEATH
<br />'c Grand Island 68803 Hall
<br />� 8a. RESIDENCE�3'TATE 8b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />� 9d. STREET AND NUMBER . APT. NO. 81. ZIP CODE 9g. INSIDE CITY LIMIT3
<br />1919 West John Street 68803 � res ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � MarHed ❑ Nevaz Married 10b. NAME OF SPOUSE (Fl�st, Middle, Last, SufFiz) NwHe, plve malden rmme
<br />� p��aa, a�r 8ape�acea ❑ v�nao�a ❑ o�o►�a ❑ u�ow� Gwendolyn Lou Strachan
<br />� 11. FATHER'S-NAME (Flrat, Middle, Laet, Suffbc) 12. MOTHER'&NAN� (Flrs; NOddle, Nlalden Sumame)
<br />m Gene Hassler Virginia Collins
<br />�' 73: EVER IN U.S. ARMED FORCES4 �iNe datea of eervice HY�. 14a. INFORMANT•NANIE 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ �r�, No, or un�c.) No Gwendolyn Lou Hassler Spouse
<br />,$ 1S: METHOD OF DISPOSITION 18a. EMBALMERSIONATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />� ❑ e�nai ❑ oonaeon Not Embalmed June 11, 2012
<br />� CremaUon � Errtombmerrt 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Speeify) �ntral Nebraska Crematlon Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUN� ADDRESS (Street, Clty or Town, State) 77b. Zip Code
<br />All Faiths Funerai Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See Instructlons and exam les
<br />1B. PART L Fstartlre shaln o(eve�disaase0.lnJuriea, or eomplicatlons�that dlreeGy eaused the deaN. DO NOT eMar tanninal eve�rtb wch aa cardlac artest, ; APPROXIMATE INTERVAL
<br />reapiratory a�reat, or veMri�wlar INrNatlon wifhout ahowlnp tlre etlolopy. DO NOT ABBfiEVIATE Fstaz ony a�re r�use on e IUre. Add add9la�l �ma It n�ry•
<br />re
<br />IMMEDIATE CAUSE: p o�et to death
<br />IMMF owre cnuse � e) Metastatic Cancer Of Colon E One Year
<br />dlaease or coiMitlon rasuRlnp i
<br />� d �� DUE TO, OR AS A CONSEQUENCE OF: � o� � d��
<br />Sequeirtlalty Ilst conditlons, B b)
<br />aeY. leaaing to the cauae Usted
<br />°D �� a ' DUE TO, OR AS A CONSEQUENCE OF: : o�et to death
<br />F�nler the UImERLVINO CAUSE �� f
<br />(dleeaee m InJury that InlUated �
<br />the eveMe resunt�re m deash) DUE TO, OR AS A CONSEQUENCE OF: � or�set to death
<br />'.nsT d) '
<br />18: PART tl. OTHER SIGNIFlCANT CONDITIONS�Comiftions coMribWng to the death but not reaulUng In the umlerlying cause given In PART I. 19. WAS MEDICAL EXAIVONER
<br />OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. NUWNER OF DEATH 21b. IF TRANSPORTATION INJU 27c. WAS AN AUTOPSY PERFORMED?
<br />� � Not P�B�t wRhln �at Y�► � Natuwl � HomlWtle � Ddved�Pararor � YES � NO
<br />v p P.�a�ffi+� ma�en � nwa.M � Pemm�p Imreatlpatlon ❑�"�
<br />��„� y,� p �„�„� w �,�, 42 ���, � p��,,, 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />,�p' � N � P �� � P �� � � � 1 � � e � ❑ s"�� ❑ C°� ^Ot � dB��"� � � �� TO COMPLETE CAUSE OF DEATH?
<br />� � un�mown H P�ae�atn Mthln the v� Year ❑ YES ❑ NO
<br />� 22a. DATE OF INJURY (Mo„ Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, famy atreet, factory, offlee building, co��struetion eke, ete. (Specify)
<br />$
<br />� 22t1. INJURYAT WORK7 22e. DESCWBE HOW INJURY OCCURRED
<br />F�-
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIGNED (Mo., DaY, Yr.) 24b. TIME OF DEATH
<br />� � June 11, 2012 B �
<br />� } 23b. DATE SIGNED (Mo„ Day, Yr.) 23e. TIAI� OF DEATH �� 24c. PRONOUNCED DEAD (MO, Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� o June 11, 2012 04:00 AM �+ <�
<br />� To the best of mY lorowatlpe, death oxurtad et tlre Urt�e. date a�M Plaee R�� 24e. On the 6ada Me�mminadon andfot 6rveadqatlon, In my opinton death oauned at
<br />$.� a�M due to tha cauaels) slaled. (SIYnaW�e and TIUe) B i$ are tMe. aate ena piace m�a aue ro tne rauee(e) effiea. (Slo�re ana nw)
<br />~ David R. Colan, MD ~ g 8
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 ZBa. HAS ORGAN OR TISSUE DONA770N BEEN CONSIDEREDT 28b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNIOVOWN ❑ YES � NO NotApplleable N28a Is NO ❑ YES ❑ NO
<br />2. IFI (P R Y U ype or Prlrn
<br />David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIONATURE 28b. DATE FlLED BY REOISTRAR (Mo, Day, Yr.)
<br />� ' June 11, 2012
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