201301544 - Laserfiche WebLink

Browse

1. DECEDENT - NAME FIRST MIDDLE LAST William Thomas Hannan 2. SEX i Male 3. DATE OF DEATH (Month. Day. Year) February 22, 2004 1 4. CITY AND STATE OF BIRTH III not in U.S.A.. name country/ Fremont, Nebraska 5a. AGE - Last Birthday (Yrs.) i 85 UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Year) July 2, 1918 55. MOS. I DAYS 1 I 5c. HOURS' MINS 7. SOCIAL SECURTIY NUMBER 508-14-7776 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient OTHER: ❑ Nursing Home 8b. FACILITY - Name (If not inssiulion, give street and number) Home: 1527 W. Stagecoach Rd. ❑ ER Outpatient .'\ ❑ DOA ❑ Residence Other (Specdm 28b. TIME OF DEATH M 8c. CITY. TOWN OR LOCATION OF DEATH Grand Island 8d. NSIDE CITY LIMITS Yes ❑s No ❑ 8e. COUNTY OF DEATH Hall 9a. RESIDENCE - STATE Nebraska 91). COUNTY Hall 9c. CITY. TOWN OR LOCATION Grand Island 9d. STREET AND NUMBER (Including Zip Code) 1527 W. Stagecoach Rd. 9e. INSIDE CITY LIMITS Yes 11 No ❑ 10. RACE - (e.g., White. Black. American Indian. etc.) lSpeciy) White 11. ANCESTRY (e.g,. Italian, Mexican, German, etc) (Specify) American 12.0 MARRIED ❑ WIDOWED 11 NEVER DIVORCED O MARRIED n 13. NAME OF SPOUSE (/1 wile. give maiden name) Wilhelmine Pauline Kobersl 14a. USUAL OCCUPATION (Give kind of work done during most of working life, even if retired) Electrical Engineer 14b. KIND OF BUSINESS INDUSTRY Silas Mason & Hanger Co. 15. EDUCATION (Specify only highest grade completed) Elementary or Seconga{.y (0 -12) Coll +l1 -4 or 5-1 L L 16. FATHER - NAME FIRST MIDDLE LAST William James Hannan 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Theresa K. Ostenberg 18. WAS DECEASED (Yes. s . or enkW EVER IN U.S. ARMED FORCES? war 1 dates 942cea) 11/14/1945 190 INFORMANT - NAME Wilhelmine P. Hannan OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART II . PART III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? n (Ages 10 -54) Yes No I I 24 AUTOPSY n Yes L I No 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? Yes ❑ No 26a. I. Accident . Undetermined • Suicide • Pending IIII Homicide Investigation 26h. DATE OF INJURY (MO.. Day. Yr./ 26c. HOUR OF INJURY M 26d. DESCRIBE HOW INJURY OCCURRED 26e. INJURY AT WORK Yes No ❑ ❑ 261. At home, farm. street factory PLACEOF i INn etc. JURY - (Specify) o ice mold 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE a , i � ° 23 •'? s f F 27a. DATE OF DEATH (M4.. Day. Yr.) February 22, 2004 To be Complele0 by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 280 DATE SIGNED (Ma.. Day. Yr.) 28b. TIME OF DEATH M 27b. DATE SIGNED (MO.. Day. Vr) -2,_1-2.- 7 /o t-f 27c. TIME OF DEATH 22:59 M 28c. PRONOUNCED DEAD (Mo.. Day, Yr./ 28d. PRONOUNCED DEAD (Hour) M 27d. To the best of my knowledge. death ocL'ed at the time, date and place and due to the ► cause(s) stated. X_�'/ 1 . / - ; , ( (Signature and Title) le / ( ; Yj 28e. On the basis of examination and•or investigation, in my opinion death occurred at the time, date and place and due to the causes stated. , (Signature and Title) OP 29. DID TOBACCO USE NTl 'fR 1 SE CO NE�T6E DEATH? UNK NO WN DONATION BEEN NONSIDERED? it7c0.a HAS ORGAN OR TISSUE YES OES 30.5 WAS CONSENT ONS GRANTED? NO 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) Ibl (0) WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL. RECORD ON €IL E WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION,--WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. =i . _ 3/10/2004 LINCOLN, NEBRASKA 1527 W. Stagecoach Rd. Grand Island, NE. 1123 West Second, Grand Island, NE. 68801 23. IMMEDIATE • . SE PART (al DUE TO, OR AS A CONSEQUENCE OF DUE TO, OR AS A CONSEQUENCE OF (ENTER0LY ONE CAUSE PER LINE FOR lal. (I, AND )c)) 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Gordon J. Hrnicek M.D. 729 N. Custer, Grand Island, NE. 32a. REGISTRAR DATE OF ISSUANCE 201301544 ,G ANLEY S. COOPER ASSISTANT sT*TERL ISTRA- HEALTH AND HUMAN SERVICES' +SYSTEM - STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES-FTIIANCEAND SUPPOR"! VITAL STATISTICS - CERTIFICATE OF DEATH 04 02 68801 20. EMBALMER - SIGNATURE & LICENSE NO. af 22a. FUNERAL HOLE - NAME Apfel- Butler - Geddes * /3RS 21a. METHOD OF DISPOSITION Burial ❑ Removal ❑ Cremation ❑ Donation 21b. DATE Feb. 26, 2004 21c. CEMETERY OR CREMATORY NAME Calvary Cemetery 21d. CEMETERY OR CREMATORY LOCATION CITY OH TOWN Fremont, Nebraska 68803 32b. DATE FILED BY REGISTRAR (Mo., Day. Yr.) MAR - 8 200A STATE Interval between onset and death Interval between onset and death Interval between onset and death e ii