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`J
<br />2 SEX •
<br />3 DATE OF DEATH /Month Oak Yearl
<br />Allen Arthur Jensen
<br />Male
<br />April 13, 2000
<br />4 CITY AND STATE OF BIRTH 111 noto U S A name country!
<br />5a AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER I DAY
<br />6 DATE OF BIRTH (Mont. 01,1 Year)
<br />Cordova, Nebraska
<br />IVrsl
<br />78
<br />M
<br />_
<br />February 9, 1922
<br />7 SOCIAL SECURTIV NUMBER
<br />8a PLACE OF DEATH
<br />506 18 6901
<br />HOSPITAL ❑ Inpatient OTHER a Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />80 FACILITY - Name pt not nsfituhon. give sheet arid number)
<br />VANWIHCS 2201 North Broadwell
<br />❑ DOA ❑ Other ;Soe,dki_
<br />C
<br />m
<br />Grand Island, Nebraska Yes © No ❑
<br />-
<br />_
<br />9a. RESIDENCE - STATE
<br />9 COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER iIricluding Zip Codel
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2413 W. Division 68803
<br />Yes ® No ❑
<br />10 RACE - leg.. White Black American Indian
<br />t I. ANCESTRY le q.. Italian. Me,ican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE fit wife give maiden name!
<br />11
<br />z
<br />"•'
<br />Rachel R. Walkama
<br />�o
<br />z -Ai
<br />N3
<br />14a 'USUAL OCCUPATION (Give kind of wore done during most
<br />14L tffl O '�t06t tqW Wnt
<br />15 EDUCATION
<br />ISpecity only highest grade completed)
<br />_
<br />ElemenTy Bed ° ^darylo.,zl College "4 °.
<br />Sta`tireglroop`er, Ret.
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDMIMAN SERVICES
<br />SYSTEM, R CERTIFE:S THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RC. - 14
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISIl10 - ,=TK14 N JV,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE _ "a
<br />APR 21 2000 200003 Ass1s,4+ LSR
<br />LINCOLN, NEBRASKA HEALTH AND HL44411 &WW,9 . TEJW-
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER�`ICES FINAf4CE rte_ }-SUPPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />I DECEDENT NAME FIRST MIDDLE LAST
<br />2 SEX •
<br />3 DATE OF DEATH /Month Oak Yearl
<br />Allen Arthur Jensen
<br />Male
<br />April 13, 2000
<br />4 CITY AND STATE OF BIRTH 111 noto U S A name country!
<br />5a AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER I DAY
<br />6 DATE OF BIRTH (Mont. 01,1 Year)
<br />Cordova, Nebraska
<br />IVrsl
<br />78
<br />Sb MOS I DAYS
<br />Sc HOURS MINS
<br />February 9, 1922
<br />7 SOCIAL SECURTIV NUMBER
<br />8a PLACE OF DEATH
<br />506 18 6901
<br />HOSPITAL ❑ Inpatient OTHER a Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />80 FACILITY - Name pt not nsfituhon. give sheet arid number)
<br />VANWIHCS 2201 North Broadwell
<br />❑ DOA ❑ Other ;Soe,dki_
<br />Bc CITY TOWN OR LOCATION OF DEATH 04 INSIDE CITY LIMITS
<br />ae COUNTY OF DEATH
<br />Grand Island, Nebraska Yes © No ❑
<br />Hall
<br />I
<br />9a. RESIDENCE - STATE
<br />9 COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d STREET AND NUMBER iIricluding Zip Codel
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2413 W. Division 68803
<br />Yes ® No ❑
<br />10 RACE - leg.. White Black American Indian
<br />t I. ANCESTRY le q.. Italian. Me,ican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE fit wife give maiden name!
<br />0c) isoeotyi
<br />White
<br />(Specify)
<br />American
<br />NEVER DIVORCED
<br />Rachel R. Walkama
<br />MARRIED_
<br />14a 'USUAL OCCUPATION (Give kind of wore done during most
<br />14L tffl O '�t06t tqW Wnt
<br />15 EDUCATION
<br />ISpecity only highest grade completed)
<br />_
<br />ElemenTy Bed ° ^darylo.,zl College "4 °.
<br />Sta`tireglroop`er, Ret.
<br />State of Nebraska
<br />16 FATHEH NAME hIHJI MIUULt LAJI
<br />r mvincn renal mi
<br />— mnrvcry —.1 -1-
<br />(Dec.) August Jensen
<br />(Dec.) Mary
<br />DeCamp
<br />n8 WAS DECEASED EVER IN OS ARMED FORCES? 19a. INFORMANT -NAME
<br />es wWI ikrwa10 9 %142I- 0/15/45 Rachel R. Jensen
<br />_
<br />1190 INFORMANT MAILING ADDRESS ISTREET OR R.F D NO, CITY OR TOWN. STATE. ZIP)
<br />2413 W. Division, Grand Island, Nebraska 68803
<br />_
<br />2C EMBALM E SIGN"' ENO -
<br />�t,G��
<br />/ , r %�/ �L�/
<br />21 a. METHOD OF DISPOSITION
<br />®Ronal ❑Removal
<br />21b. DATE 21c CEMETERY
<br />Apr. 17, 2000 Westlawn
<br />ORCREMATOHY NAME
<br />Memorial Park
<br />22a N RAL HOME . N E
<br />21d CEMETERY OR CREMATORY LOCATION
<br />CITY OR TOWN STATE
<br />Livingston - Sondermann F.H.
<br />❑Cremation ❑Donation
<br />Grand Island,
<br />Nebraska_
<br />22b FUNERAL HOME ADDRE ;S (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />_
<br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ibl. AND (c)l
<br />Interval bel,veen onset and death
<br />PART
<br />lal Aspiration Pneumonia
<br />I
<br />24 hours
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />1 Interval between onset and death
<br />". Stroke. .. - -
<br />I
<br />9 worths
<br />(hl.
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />,l
<br />- Interval between onset and dean
<br />I
<br />Ic) I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS° EXAMINER OR CORONER'
<br />II Coronar y arter y disease
<br />IAgea,D -541 Yas i No ❑ Yes [j Nd [X] Yea ❑ Nd [� _
<br />26a 26b DATE OF INJURY /MO.. Day. YrJ 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />1-1 4cadent Jndetermmed M
<br />n S—de ❑ Pending 26e INJURY AT WORK 261 PLACE OF INJURY - At home. farm. street. factory 269. LOCATION STREET OR R F D. NO CITY OR TOWN STATE
<br />❑ ❑ office building. etc ftlt )
<br />Ho-ode mveskgaoon Yes No
<br />27a DATE OF DEATH /MO. Da, Yr.l 28a DATE SIGNED /MO. Day Yr I 28b TIME OF DEATH
<br />April 13, 2000
<br />�< s M
<br />27b. DATE SIGNED . Day vrl 27c. TIME OF DEATH ° 28c. PRONOUNCED DEAD IMO. Day. Yr I 28d. PRONOUNCED DEAD (Hour
<br />,
<br />April 17, 1M0 2000 5:30 p M M
<br />° 27d To the best of my knowledge death occurred at the t date and place and due to the ° °a ° 28e. On the basis of examinatwn and or Investigation. In my opinion death occurred a1
<br />causelsl stated. �i �vv^i1� ~ ° 3 the ante, date and place and due to the cause(sl stated.
<br />ISi nature and T41e1 ► SI nature and Title ► _
<br />29 010 TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />® YES F] NO 11 UNKNOWN 1:1 YES ® NO 0 YES O NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PRY °ICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Typed" Pnnll
<br />Ramchandra N. Kamath, M.D•A VANWIHCS/22A1 North Broadwell, Grand Island, Nebraska 6880
<br />
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