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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Harvey James Johansen 2. SEX Male 3.' DATE OF DEATH (Mo., Day, Yr.) February12, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Farwell, Nebraska 5a. AGE - Last Birthday (Yrs.) 86 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) January 18, 1925 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -28 -8904 8b. FACILITY -NAME (If not Institution, give street and number) Grand Island Veterans Home 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1316 N. Huston Ave. 8e. APT. NO. ! 8f. ZIP CODE 1 8g. INSIDE CITY LIMITS 68803 I Ei YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Ruth Anderson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Peter Johansen - 12. MOTHER'S -NAME (First, Middle, Malden Surname) Isabelle Harvey 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 01/23/1945- 04/25/1946 14a. INFORMANT -NAME Ruth Johansen 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c, DATE (Mo., Day, Yr.) February 15, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART I. Enter the ghain of events -- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 1 Week respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a fine. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Influenza A disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentlally list conditions, it b) any, leading to the cause listed fine on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death'-«' not resulting In the underlying cause given In PART 1. Coronary Artery Disease, Vascular Dementia Stage 7 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 0. IF FEMALE: ID Not pregnant within past year Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DE ® Natural ❑ Homicide ❑ Accident ❑ Pen investigation ❑ Suicide ❑ Could determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger ❑ Pedestrian ❑ Other (Specify) 21 c. WAS AN AUTOPSY PERFORMED? ❑ YES ® ND 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a W 1 E r E U z z 23a. DATE OF DEATH (Mo., Day, Yr.) February 12, 2011 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) F ebruary 14, 2011 23c. TIME OF DEATH I 10:35 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 u 0 3d. To the best of my knowledge, death occurred at the time, date and place c and due to the cause(s) stated. (Signature and Title) W Jennifer King, MD 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ❑ YES ISSUE r • 11 NO ATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE A1119 ADDRESS of CERTIFIER (PHY SICIAN, FHYSIC!AN ASSISTANT CORONE HYSICIAN OR COUNTY ATORNEY) (Type or)'rint) Jennifer King, MD, 2300 West Capitall Avenue, Grand Island, Nebraska, 03 28a. REGISTRAR'S SIGNATURE S �J , 5 rrr 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 14, 2011 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL HAND i IUMAN' SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA OEPARtMEWT Pr HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR l%ITALI'ftE 6� DATE OF ISSUANCE 03/08/2011 201604428 SI ST Y A S COOPER AS STATE REGIS A TRAR . DEPARTMEN? OF HEALTH 'AND LINCOLN, NEBRASKA . 41UM31It'r!1r✓ES . ' ' . STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 11'00438