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1. DECEDENT - NAME
<br />e. CITY AND STATE OF BWTH IN not
<br />Dannebrog, NE
<br />?. SOCIAL SECURITY NUMBER
<br />. 508-09 -3095
<br />b. FACILITY - Name (N not
<br />St. Francis.
<br />1. RESIDENCE - STATE
<br />Nebraska
<br />9191
<br />1 0. RACE - (e.g., Whet Black, American Indian,
<br />Mt.) (Spcay)
<br />White
<br />in
<br />PART
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />Ibi
<br />DUE TO, OR AS A � OF
<br />271 DATE OF DEATH (AM.. Dry, Yr
<br />JUN 0 2 2015
<br />LINCOLN, NEBRASKA
<br />FIRST
<br />16. FATHER - NAME FIRST MIDDLE
<br />(Ye n es d
<br />e. no, or k.l in yea, give war and dates *annual
<br />PART *mew SE ENT UNE ONLY ONE CAUSE PER E FOR lilt lb), AND Icli
<br />1s1 l .-s L J A
<br />Arvon Rodger Jensen
<br />OTHER F ICNCON OI O } ITIONS - Condemns co 151b 0rig b deem n but al r (Med
<br />26a. ACCIOENT. SUICIDE, HOANCIOE, UNDET., 126b. DATE OF INJURY ni1. Yr.) 126c. HOUR OF INJURY
<br />OR PENDING INVESTIGATION (*Rudy/
<br />26e. IN AIRY V AT WORK ) 26. PLACE OF INJURY - At Mme. farm, *..t. Mabry.
<br />(Spacayy Yes a NO once buNdng. ale. (Sway)
<br />Ib- C � r
<br />27b. DATE SIGNED (Mo., Day, 1?) 27c. IME OF DEATH
<br />beef d my kno at the time
<br />27d. To *.e
<br />caueels) *baled.
<br />(Sipwre w and rem)►
<br />290- DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES )W NO U UNKNOWN
<br />M1DDL0
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT AF. HE,ALTI AND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORbtON
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS,
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH ,
<br />20a. HAS 0..3AN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YEb
<br />LAST
<br />26c
<br />2. SEX
<br />Male
<br />29*. DATE. SIGNED /Mo., Day Yr.)
<br />26c, PRONOUNCED DEAD /Ma, Day. Yr)
<br />31. NAME AN0 AGGRESS CERTIFIER (PHYSICM4, CORONER'S PHYSICAN OR COUNTY ATTORNEY) /Type or Pun/)
<br />Dr. J.J. nnella 7,9 North Custer Grand island, Nebraska 68803
<br />DATE OF ISSUANCE
<br />.
<br />3. DATE OF DEATH (Mom D V
<br />October 5, 1992
<br />6. DATE OF BIRTH plon1A, Day, YY901
<br />March 23, 1919
<br />9c. CITY, TOWN OR LOCATION OF DEATH 18d. (Spltl M4SIOE y Yw CITY U d iNiTo) COUNTY OF N. COU OF DEATH
<br />Grand Island, Nebraska 1 Yes Hall
<br />201700628
<br />STANLEY gOOPER
<br />ASSISTANT STATE REGISTRAR.
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />32a REGISTRAR
<br />PART M IF FEMALE. WAS THERE A 24. AUTOPSY
<br />PREGNANCY ties THE PAST 3 MONTHS? 1 (5DKAy Yes
<br />Y es O No O
<br />DESCRIBE HOW INJURY OCCURRED
<br />92...11674
<br />n van., no country)
<br />*m ore. give street and nMnW)
<br />ical Center
<br />90. COUNTY
<br />Hall
<br />5e. AGE - Lao BMedey
<br />(Yrs.)
<br />73
<br />I IVDFR 1 DAY
<br />50. HOURS- MINS.
<br />UNDER 1 YEAR
<br />5b. MOS. ( DAYS
<br />8. PLACE OF DEATH VVGG
<br />q
<br />HOSPITAL: orpNiMt ❑ ERJOuubatied 0 DOA •
<br />R:
<br />I T 0 Nursing Home • 0 Residence ❑ Other (Speedy)
<br />90. CITY. TOWN OR LOCATION
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />4213 Sout
<br />oa)
<br />(including ad Co a.. 0E CITY VMS
<br />ROM* V
<br />h Engleman Rd. No « per
<br />11. ANCESTRY (e4Aak (UMW. Mexican. MO 12. MARRIED,NEVER MARRIED. 13. NAPE OF SPOUSE p' B pea Alaiden i .
<br />A erican Ma tried D/ ) 1 Leah L. Thomssen
<br />14*. USUAL OCCUPATION (Give kind W work done during moat 14b. KIND ;r BUSINESS INDUSTRY f 15 FMNCATION ISbarJtx met h aide ielemt
<br />a, Wo. even M need 3 EMnomry or Secondary (0-121 • 1 Camp 0.-4 or 5.1 Farmer `� 1 A gricultural 0 " 12th
<br />LAST 17. MOTHER - MAIDEN NAME FIRST MIDDLE
<br />•
<br />280 TIME OF DEATH
<br />306. WAS CONSENT GRANTED?
<br />YES
<br />LAST
<br />Alfred - Jensen Martha - Sorensen
<br />19. WAS DECEASED EVER IN U.S. ARM R R.
<br />ED FORCES? - -. 19. INFORMANT - NAME - MAILING ADDRESS (STREET OF.D. NO., CRTY OR TOWN. STATE. 2IP)
<br />Yes WWII 2- 19-41 9- 28--45 Leah Jensen 4213 S Engleman Rd Grand Island, NE
<br />20a. BURIAL, Camaaon,Removel 200. DATE C;Cn raJ� ° e` raslta""'"Crerlation 20d. LOCATION- CITY OR TOWN STATE
<br />Donation
<br />Cremation t. 5, 1992 Service Gibbon, Nebraska
<br />EMBALMER - SIGNATUR.. 8 LICENSE NO 22. FUNERAL HOME - NAME AND ADDRESS (STREET OR R.F.0. NO.. CRT' OR TOWN. STATE. 296)
<br />4. - 7 - c4e B ya- Apfel - Butler- Geddes 1123 W 2nd Grand Island, NE 68801
<br />m11nvsi :between onset and dhow
<br />kaenai between onset and dSesl
<br />Marvel between ,neat aAe des*
<br />26g. LOCATION STREET OR R.F.D. NO. CRT' OR TOWN STATE
<br />26a. PRONOUNCED DEAD ('
<br />L M
<br />269. On eve basis of sxsmneaon arrVor .nwema9M0n, in my opinion dea* occurred at
<br />t o hiss, dam and plebe and d s to tree cw»(e) sited.
<br />( (Srgrauura end Tate( IP
<br />
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