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STATE OF NEBRASKA
<br />WHEN '< THIS ' COPY CARRIES THE RAISED SEAL OF 'THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />03/11/2016
<br />LINCOLN NEBRASKA
<br />18, PAWL Enter the chain of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Chronic Obstructive Pulmonary Disease
<br />disease or condition resulting
<br />in death)
<br />Sequentially lint conditions, if
<br />any, leading to the cause listed
<br />Enter the UNDERLYING CAUSE
<br />Idisease or injury Mat mttiatad �.
<br />Ole events reaulting, in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE
<br />b)Tobacco
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />1 Year
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. ( 19. WAS MEDICAL EXAMINER
<br />I OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />216. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABL
<br />TO COMPLETE CAUSE OF DEATH'Y;:
<br />❑ YES ❑ NQ
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />® YES ❑ NO 0 PROBABLY ❑ UNKNOWN ❑ YES ® NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Brian. K. Buhlke,<DO, 2510 18th Avenue, Central City, Nebraska, 68826
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES la No
<br />r 0. IF FEMALE:
<br />❑ Not pregnant within past year ❑ driver /Operator
<br />❑ Pregnant at time of death ❑ P
<br />❑ Not pregnant: but pregnant within 42 days of death
<br />❑, Not pregnent,:but ptegnant43 days to 1 year before death
<br />❑ unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc: (Specify)
<br />22d. INJURY AT WORK? •
<br />❑YES NO
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 4, 2016
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b, TIME OF DEATH
<br />23b. DATE SIGNEb (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />March 7, 2 04:15 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />•
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />7. SOCIAL SECURITY NUMBER
<br />505 -54 -4833
<br />84. FACILITY -NAME (If not Institution, give street and number)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes; NO, or Unk.) NO
<br />5. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER - SIGNATURE
<br />Tracey Dietz
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Sta
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />14a. INFORMANT -NAME
<br />Eileen Hansen
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />Ill 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />re
<br />p Grand Island 68801
<br />9a. RESIDENCE -STATE 9b. COUNTY 9t;. CITY OR TOWN
<br />to Nebraska Hall Grand Island"
<br />7 9d. STREET AND NUMBE
<br />T 1124 West 10th
<br />15 10a. MARITAL. STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />ru
<br />it: ❑ Married, butseparated ❑ Widowed ❑ Divorced ❑ Unknown Eileen Robinson
<br />sr
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />9e. APT. NO.
<br />16b. LICENSE NO.
<br />1328
<br />OTHER ❑ Nursing Home /LTC ❑ Hospice Facility
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />CITY /TOWN
<br />Westlawn Cemetery Grand Island
<br />CAUSE OF DEATH See instructions and exam•les
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS:'
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DEC EDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />March 8, 2016
<br />28b. DATE FILED BY REGISTRAR (Mo.,. Day, Yr.)
<br />March 9, 2016
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gene E Hansen
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE Last Birthday -b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (MO,, Day
<br />Grand Island, Nebraska
<br />S. OPER
<br />2 U J. 6 0 3 9 7 41 ASS S S AT E REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />(Yrs.)
<br />72
<br />2. SEX
<br />Male
<br />August 3, 194
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 4, 2016
<br />Yr:
<br />
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