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<br />STATE OF NEBRASKA
<br />1
<br />WHEi�I THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, I7" CERTIFIES
<br />.THE BE�OW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />' HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAt RECORDS.
<br />DATE OF ISSUANCE ��/��a� � � ��
<br />STANLEY 5 COOPER
<br />FE� �' � 2O 10 � DEPARTMENT O HEA � H AND
<br />LINCOLN, NEBRASKA � o � � � � � � � HUMAN SERVICES
<br />STATE OF NEBRASKA- DEPAF�TMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO g Z g 214
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTB-NAME (Flret, Middle, Laet, Suttlz) 2.8EX 3.DATEOFDEATH (Mo.,Dey,Yr.�
<br />Gerald Eugene Hensley Male October 9, 2009
<br />4. CITY AND STATE OR TERR�TORY, OR FOREION COUNTRY OF BIRTH 6a. A�E-Lest Blrthdey 6b. UNDER t YEAR bc. UNDEH 1 DAY B. DATE OF BIRTH (MO., Dey, Yr.)
<br />Central City, Nebraska �Y`e.� 79 M08. DAYS HouAS mws. March 24, 1930
<br />7. SOCUU. SECURITY NUMBEH Ba FlACE OF DEATH
<br />506-28-7591 }l9.SPLTAL: OlnpeNent Q�yE$ �NureNgHomelLTC �HoaplceFflciAty
<br />Bb. FACILITY•NAME (If not fnetltuUOn, glve etreet and number) ❑ Ep�putpatient ❑ DecedenPaHOma
<br />Tiffany Square Care Center o � o ����
<br />80. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH -
<br />' Graad Island 68803 Hall
<br />9e.RE310ENCESTATE Bb.COUMY 9c.C(TYOHTOWN
<br />Nebraska Hall Wood River
<br />9d, BTREETAND NUMBER 8e. APT. NO BI. LP COOE
<br />104 East 13th 68883
<br />t0e. MAHITAL STATUS AT TIME OF DEATH �Manled O Nevet Manied 106. NAME OF 8POU8E (Flrat, biiddle, Leet, 3uHix) It wRe, glve melden name.
<br />❑ M�i�a but sepereted ❑ Wldowed 0 o�+a«aa v uok�o.m Marian Mae Craf t
<br />8g. IN81DE CITY LIMRS
<br />� YES ❑ NO
<br />11. FAYHER'9•NAME (Pltat, Mlddle, Laet, Suttix) 12. MOTHER'S•NAb1E (Flrat, Mlddle, Maiden 8umame)
<br />Joseph E'. Hensley Jesse C. Breckon
<br />13. EVER IN U.S. ARMED FORCE89 aive detea oi service tl yes. 14a. INFORMANT NAME 14b. RELATIONSHIP TO DECEDENT
<br />�v�s,Xo?�o�„f,x.► 2/1/1951 1/25/1955 Marian Hensle Wife
<br />16. METHOD OF DISPOSITION 18e. � 18b. LICENSE N0. 18c. DATE (Ma.. DeY. Yr. j
<br />�a,� vo�no� /,?y� October 14, 2009
<br />❑Crematlon ❑Entombment 18d.CEMETERY,CREMATORYOROTHERLOCATION CITY/TOWN 3TATE
<br />❑Removel ❑oma�tsa��+v� Grand Island Cemetery Grand Island, Nebraska.
<br />17a FUNERAL HOME NAME AND MAILINO ADDRE83 (Street, City otTown, State) 17b. Zip Code
<br />Apfel Funeral Home, 1123 West Second, Grand Island, Nebraska. 68801
<br />1& PART L Enter the chaln of eveMa-dieaflsee, lnJurles, or eomplloaUona»Nat Cirectly ceuaed the deatfi. DO NOT emer terminal evanle auc� es eerdlao erres6 ' �PR��TE �rvreRVnt
<br />I
<br />respirawry erteat, or veMrlcular fmrlllallon wlthout showing the e8ology. DO NOT ABBHEVIATE. EMer oNy one cause on e Me. Adtl additlonal Ilnes tl necesaery. i
<br />IMMEOIATECAUSE: � onsettodeath
<br />IE7b1EDIAiECAU$E(Fhml (� M1�,� �'�.S ��`���• i � ' \ ��\� �
<br />�����8 DUETO,ORA9ACONSE�UEN OF: � onsetlodeath
<br />ind88tlt) i
<br />ee�mruatoo�tto�aq ro� Al�VP�ro�Cs�.�C,��v�'-, C�YJ�l1u ����R.�1i�]w.,fi��k i yQ�
<br />�'��"B DUETO,ORASACONSEUUENCEOF: I ansettodeath
<br />on ilrre e. .
<br />�cmcreunmEn�nNflCausE C� Y'�11.C� ��f�Onr\�� SI�Nl�fO�� � i�
<br />(diseesamlrtJurythatlntdeted (°1 ,��' i
<br />�����) " DUETO,ORABACONBEQUENCEOF: ' � anaettoda&lh .� �
<br />lA4r �
<br />(� � �
<br />18. PART II.OTHER SI�NIFICANT CONDITIONS-Condidone Lrontributing to ttre death but irot rasu�Ung In lhe iu�dedyfng ceuse given tn PART I. 19. WAS MEDICAL EXAMINEH
<br />� � ��� 1 ��V��1tl�SNfl( DX. � I'�nC/Vt�/o���� O YE30NERCQ oACTED?
<br />♦ 1 ��
<br />20.IFFEMALE: 21aMANNEROFDEATH 276.�F7RANSPORTATIONINJURY atc.WA3ANAUTOP9YPERFORIdED7
<br />❑ Not pregneM within past year �Neturel 0 Homidde 0 DrlvedOperatot
<br />��� ❑ YES �NO
<br />❑ Pregnent et tlme of death ❑ Aoeldent0 Pending ImestlgaUOn
<br />❑ Notpregnem,butpregnentwtthln42deysofdeeth � 21d.WEREAUTOP3YFlNDiNO3AVAILABLETO
<br />0 Sulolde ❑ Couid nm be determined ��r (9pecify)
<br />❑ Notprepnarn,bulpregirent43deyelotyearbeforedeath COEEPLElECd�USEOFDENH7
<br />O, Unknown If prepnantwit{Unthe pestyear ❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY At home, farm, sVeet, fecWry, oHice 6uilding, conahuctlon atte, em. (Speclry)
<br />N i� m - --- --
<br />22diNJUH'fAT�PYORRT� � - Ple. - 6E5'CFi1BE I�OWINJUpYOCCUHRED - . - --- --
<br />❑ YES Q NO �
<br />�I.L�ATIONOFINJURY-3TREEf&-NUMBER,APT.NO, qTYlfOWN BfATE ZIPCODE
<br />23a.DATEOFDEATH (Mo.,Day,Yr.) 24a.DATESIONED (MO.,Uay,Yr.) 24hTIME0F0EATH
<br />.�'� � •- �l- Oc1 .��� m
<br />�2 �} 23b.DATESIpNED(Mo.,Day,Yr. 23c.TUdEOFDEATH ��� 24C.PRONOUNCEDDEAD(MO.,Dey,Yr.) 24d.TIMEPRONOUNCEDDEAD
<br />'� l0_\3`-u� m ama� m
<br />23E. To the beat knawle e, d n fhe tlme, dete end place �� 24e. On Ihe besle o1 exeminetton arWlur InveatlgaNOn, in my opinlon tlealh oocurted et
<br />�� end d o the us ete (&Ignyture nd Tttte )♦ � p� the tlme, dete end piaae and due m the cause(s) ateted. (Signature end Title )♦
<br />�; ¢
<br />$$
<br />?b.DID70BACC0USEC6NTHIBUTET0THE0EATH7 28a.HASOROANORTIS3UEDONATIONBEENCONSIDEREq7 286.WA9CON8ENTQRANTED7
<br />❑ YES ❑ NO PROBABLY ❑ UNKNOWN ❑ YE9 0 Not Appllceble II 28a ie NO ❑ YES � NO
<br />27.NAME,TITLEANDADDR 9SOFCERTIFlER (PHYBICUW,CARONEH'3PHYSICIANORCOUMYATTORNE`� (lypeorPriN)
<br />Steve Husen M.D. 2116 W. Faidley Ave., Grand Island, 68803
<br />28a REOISTRAH'831aNATURE 28b. DATE FILED BY REaISTRAR (MO., Day, Yr.)
<br />h r,�,_ _ ,t �.�...,._ ocr 2 � Zoos
<br />HHS-81 11/03 (b5081)
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