|
STATE OF NEBRASKA
<br />WHEN TH/S COPY CARRIES THE R.41SED SEAL OF THE NEBRASKA HEALTHAND HUMAN SERVICES
<br />SYSTEM, IT CERTIF/ES THE BELOW TO BE A TRUE COPY OF THE OR/G/NAL RECQRD:.QN FlLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, V/TAL STATIST�CS ����Q�� W'HI,CH IS
<br />�
<br />�q �.
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS � r, b'�' ,. �. `�''� A, ,'� '� r
<br />�o12os52ti _ �;�-:� .� �, � �,�.
<br />DATE OF /SSUANCE � ,
<br />�� - �++f -• �? Iucr�9
<br />h,�Af� � `� ��0� � A��`e' ra�m��r�s. co���R..,
<br />T �'GIST14AXt
<br />UNCOLN, NEBRASKA - - - HE�L �9 '�1 �N $ RVECES ; "F
<br />A9�4
<br />� � . ..
<br />'', ; � � ° c
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FIIV��VCE&I�D,� , � a� �
<br />CERTIFICATE OF DEATH °` � `°< ' ����G � 3 �
<br />1. DECEDENT'S•NAME (Flret, Middle, Leat, SufBx) 2: SEX • l�f�pq (Mo.,Day,Yr.)
<br />Victor Gerald Jensen Ma.le ~��'�. ,�March 7, 2008
<br />4. CITY AND STATE ORTERRITORY, OR FOREION COUNTHY OF BIRTH 5a. ADE-Lest BlAhday 6b. UNDER 1 YEAR 6c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.j
<br />(Yre.) MO3. DAYB HOURS MINB.
<br />Giltner, Nebraska 83. August 23, 1924
<br />7.60CIALSECURITY NUMBER Ba PLACE OF DEATH
<br />505-22-9669 HOSPITAL ❑m oTM�t �1NuraingHOme/LTC OHosplceFacllily
<br />Bb. FACILiri•NAME (If not InetNutlon, give etreat and numberJ ❑ ERlOutpedenl ❑ DecedenPeHoma
<br />Tiffany Square v �_ U ����_ _ _
<br />8a CITY OR T01NN OF DEATH pnctude Zip Code) 8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />Ba RE8IDENCE-8TATE 0�. COUNTY Ba CRY ORTOWN
<br />Nebraska Hall Grand Island
<br />Bd3TREETANDNUMBEH Be.APT.NO Bf.ZIPCODE Bg.IN91DECfTYLIMiTS
<br />1108 South Cherry Street 68801 A�I YES ❑ No
<br />t 0a. DAARITAL STATU9 AT TImE OF �EATH �1 Marr�ed Q Never Merrietl tOb. NAME OF SPOUSE (Flrat, Middle, Leaf, SWfiz) If vrife, give melden neme.
<br />❑mar�iea ,buteeparaied OWidowed ❑Divatced ❑Unknown Marian Ida Wilhelmi.
<br />11. FATHER'S•NAME (Flret; Middle, Leat, 3uHi:) 12. ALOTHER'&NAIdE (Firat, Mlddle, blalden Surnemet
<br />Irvie P. Jenaen Mabel E. Salmon
<br />13. E4ER IN U.S. ARMED FOliC a�s of servtce Ryes. 14a INFORWANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yea,no,orunk) pe8 '�� 1 ���6/1948 Marian Jensen Wife
<br />18. METHOD OF DIBPOSITION 18e. EMBALMER-SIpNATURE 18b. UCEN3E N0. 1 Bc. DATE (Mo., Dey, Yr. )
<br />oeu�e� ❑Donetlon aot embalmed ---- March 7, 2008
<br />�CremaBon ❑EntomDment 18d•CEbIETEFiY,CRE1dATORYOROTHERLOCATION CITYlTOWN BTATE
<br />❑ Removal � ❑ Other (SpeoHy)
<br />Weatlawn Memorial Park Crematory Grand Ialand, Nebras'ka
<br />17a FUNERAL HOME NAMEAND MAILINO ADDRESB (9treet, CftyorTovm, 8tete) 17b. Zip Coda
<br />�pfel Funeral Home 1123 West 2nd Street Grand Island, Nebraska 68801
<br />�
<br />__ ❑ YES j] NO- - I
<br />_ _ -- ---- - -- - - -
<br />_ - -- I _ -' -
<br />Y1f. LOCATION OF IN,IURY • STREEf & NUMBER, APT. N0. CIIYlfOWN � SOQE ZIP CODE
<br />m
<br />�d.IWURYATWORK7 72e.DE&CRIBEHOW�NJUHYOCCURHED
<br />1& PApT I. EMaz the cheln ni events-�dlaeasea, InJwles, w comppoeqona-tpet directly cauaed the death. DO NOT entar terminel erenta euch es cardleo erteat, � �P��1E INTERVAL
<br />resplretory arreat, or trenMculer Mrlllatlon wflhout ehowing ihe etlology. DO NOT A88HEVIATE. Enmr oniy orre cause on a Une. Add edd(tlonal Wree M neceasery. �
<br />IIdMED CAUSE: � anselMdeflth
<br />���,� �� a , ✓►�a V► 5 �cc. � ' d�y°
<br />� DUETO,ORA3ACON8EQUENCEOF. i o tmdeath
<br />indeaih) �
<br />Sequent�0yl�tcondiUame,H @) �
<br />�'��� DUETO,ORASACONSEdUENCEOF: I onaetMdeath
<br />on nne a.
<br />ErdarBteUDIDFALYW0�I�RE �
<br />(ms�eorinpuyumttnRleted (�) �
<br />�
<br />�����f DUETp,ORABACON3EDUENCEOF. � pnsetrodeath
<br />U�!
<br />I
<br />(� I
<br />7B. PART II.OTHER SIONIFICANT CONDITION&COnditlona wnMbull� ro the deaN but nol reaWting In the underiying rause given in PAHT I. 10. WAS tdEDICAL E%AMINER
<br />� 1 ""( f C r1'K � 1. `G {`�' / �.� �+� 4` Ci � � � w OH COflONEfl CONTACTED?
<br />� « v u ry+ O YES NO
<br />20.IfFEMALE: 21aMANNEROFDEATH 21b.IFTRANBPORTATiONINJURY 21aWA3ANAUTOP9YPERFORMED4
<br />❑ NotpregrrentwithNpastyeer �Iaturel ❑Homidde ❑DrivedOperetor ❑ YES �NO
<br />❑ Pregnantettlmeofdeath ❑AccidentOPendinglmestlgatlon �P�"8er
<br />O Not prepnent, but pregnent wilhln 42 deys ot death O 3ulaide ❑ Could not be determined � P�� 21d WERE AUTOP9Y FlNDIN�S AVAlIA8LET0
<br />❑NotpreAnan4butPreBnent43dayeWlyearbeforedeeth ❑Other(SpecNy) COO�LETECAUSEOFDE/RFI1
<br />❑ Unknown R prepnent wfthln the paet year O YES NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 220. pLACE OF INJUFY-At home, farm, etreet,lactary, oifloe bullding, consUuellon aite, etc. (Specity)
<br />23a. DATE 0� DEATH (MO., Day, Yr.) 24e. DATE 91�NED (Mo.. Day, Yc) 24b.TIME OF DEATH
<br />� March 7, 2008 y.�� m
<br />� 23b.DATESI�NED(Mo.,Dey,Yc) 23c.TIMEOFDEATH ��� 24aPRONOUNCEDDEAD(Ma,Day,Yr.) 24d.TIMEPRONOUNCEDDEAD
<br />� - -O cy : /1 �m �a� m
<br />�� 23d. To the best of my knowledge, death occurted et Ne time, tlate aml ptece ���� 24e. On the beels of exeminetlon erMlor Inveetlgatlon, in my apinion death accurted at
<br />and e ro the cause(s) eteted. (Slgneture end TIUe )♦ .� g� tha Ume, dete and plece end due to the ceuse(s) steted. (Signeture end Title )♦
<br />�iJ $ g
<br />25.DIDTOBACW USECONTRIBUTETO DEATH? 28e. HAS OR(3AN OHTfBSUE DONATION BEEN CONSIDEREDT 28b. WAS CONSENT ORANTED4
<br />❑ YE9 NO ❑ PROBABLY ❑ UNKNOWN ❑ YE8 NO Not Appliceble It 2Be le NO ❑ YE9 � NO
<br />27.NAME,TITLEANDADDRESSOFCERTIFIER (PHYSICIAW,CORONER'SPHYSICIANORCOUN7YATTORNEYI fNoeorPriMl
<br />28e. RE�IBTRAR'3 SI�WUURE �
<br />�
<br />28b. DATE FILED BY REpI3TRAR (MO., Dey, Yc)
<br />fYl/ � � 2�
<br />�
<br />HH9-81 11l03 (55081)
<br />
|