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• r WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AN„ 1414,7MbN ∎gRVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL:RE,MN ppi FILE' IV.(TH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTi SECTIO.N 64 Ci / THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE MAY 2 9 2000 LINCOLN, NEBRASKA 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 9e. APT. NO 9f. ZIP CODE 2004 W 12 St. 68803 iSa. MARITAL STATUS AT TIME OF DEATH Married ❑Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give maiden name. ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Nels Peter Jensen 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes, no, or unk.) No 5. METHOD OF DISPOSITION ❑ Burial ❑ Donation IMMEDIATE CAUSE (Final disease or condition resulting in death) Sequentially list conditions, if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE (disease or Injury that initiated the events resulting In death) tAST Igl Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 3d.To the nd due to Middle, 9b. COUNTY Last, Suffix) 16a. EMBALMER- SIGNATURE ( Not Embalmed ) DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: stated Bonnie Lou Williams 14a. INFORMANT -NAME Bonnie Jensen 16d. CEMETERY, CREMATORY OR OTHER LOCATION 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Kleine Funeral Home, 3213 W North Front St., Grand Island, NE 9c. CITY OR TOWN Grand Island 16b. LICENSE NO. HOURS MINS. 8d. COUNTY OF DEATH Hall 12. MOTHER'S -NAME (First, Middle, Anna Hansina Hansen Central Nebraska Cremation Service, Gibbon, Nebraska 18. PART I. Enter the chain of events -- diseases, injuries, or complications - -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or veniricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. IMMEDIATE CAUSE: + ' onset to death CI> OA onset to death onset to death onset to death 9g. INSIDE CITY LIMITS tit YES ❑ NO Maiden Surname) 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr. ) May 23, 2008 CITY /TOWN STATE 17b. Zip Code 68803 APPROXIMATE INTERVAL 1. DECEDENT'S -NAME (First, Harlan Lee 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Dannevirke, Nebraska 7. SOCIAL SECURITY NUMBER 507 -32 -7756 8b. FACILITY -NAME (If not institution, give street and number) 2004 W 12 St. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED ❑ YES pQNu 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. 23e. DATE OF DEATH (Mo., Day, Yr.) May 22. 2008 23b. DATE SIGNED (Mo., Day, Yr.) May 23, 2008 28a. REGISTRAR'S SIGNATURE my knowle causes 25. DID TOBACCO U ONTRIBUTETOTHE DEATH? STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SFAPP CERTIFICATE OF DEATH Middle, Last, Jensen 22b. TIME OF INJURY m 23c. TIME OF DEATH 4:00 P m CITY/TOWN eath occur ed at the time, date and place (Signatu g and Title) STATE OF NEBRASKA 5a. AGE -Last Birthday (Yrs.) 75 ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined Suffix) 5b. UNDER 1 YEAR PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. 20. IF FEMA E: ) NNER OF DEATH 1 21b. IF TRANSPORTATION INJURY ❑ Not pregnant within past year wN etural ❑Homicide ❑ Driver /Operator ❑ Pregnant at time of death ❑ Passenger ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to I year before death ❑ Unknown if pregnant within the past year 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ Pedestrian ❑ Other (Specify) 2. SEX Male C 4Nd Ey S. COOPER ASSISTANT S AT 13EGI,STffAR HHALT/'t AND HUMAN SERVICE'S 5c. UNDER 1 DAY '3. DATE OF. DEATH' (Mo., Day, Yr.) May 22, 2008 6. DATE OF BIRTH (Mo., Day, Yr.) February 2, 1933 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient 011E6 ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER /Outpatient )1, Decedent's Home ❑ DL14 ❑ Other (Specify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 26b. WAS CONSENT GRANTED? 19. WAS MEDICAL EXAMINER OR CORONER CO TACTED? ❑ YES e NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES •tro 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES WI) STATE ZIP CODE 24b.TIME OF DEATH 24d. TIME PRONOUNCED DEAD m m 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) ❑ YES ❑ NO PROBABLY ❑ UNKNOWN ❑ YES 'd'g Not Applicable if 26a is NO ❑ YES YLTNO 27. NAME, TITLE AND ADD ESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Dr Ryan D Crouch DO 800 Alpha Grand Island, NE 68803 28b. DATE FILED BY REGISTRAR (Mo., DaIYr.) I MAY 2 7 2008 HHS -61 11/03 (55061)