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6 Nc4A " 0 1i , 11 -Z :i w kNkgrt N2,1,42t. Wirt/ YJ7_ n %.l �dl 91sY` ^ J,( ate\ y *OA . teaII i.1. w 5 S<J JZ 'a d 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Robert Carrol Hansen 4. CITYAN Blade 7. SOCIAL SECURITY NUMBER 505 -36 -9043 8b. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 1803 W 8th Street 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married Married, but separated ® Widowed ❑ Divorced ❑ Unknown WHEN ? THIS " COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 201702275 12/23/2016 LINCOLN, NEBRASKA D STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH , Nebraska 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harry D Hansen e • 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. E 8 ( Yes, No, or Unk.) No 15. METHOD OF DISPOSITION F ®Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ <Removal >;❑ Other (Specify) IMMEDIATE CAUSE (Final disease or condition resulting in death) Sequentially list conditions, if any leading to the cause listed on line a 1 4b. COUNTY Hall 16a. EMBALMER-SIGNATURE Dane Cemetery DUE TO, OR AS A CONSEQUENCE OF: b)Aspir3tion DUE TO, OR AS A CONSEQUENCE OF: c) Failure To Thrive Enter the UNDERLYING CAUSE .idisease or injury. that initiated the events resulting in death{ • DUE TO, OR AS A CONSEQUENCE OF: LAST d) 20.1F FEMALE: f' ❑Not pregnant within past year ❑ Pregnant at time of death ❑ Not pre gnant, put pregnant within 42 days of death ❑ Not pregnant, abut pregnant t3 days to I year before death ❑ unk now n If pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) a. VATS OF DEATH (Mo., Day, Yr.) December 11, 2016 b. DATE SIGNED (Mo., Day, Yr.) December 12, 2016 3d. To the best of my knowledge, death occurred at the time, date and place and doe to the causels) stated. Signature and Title) Ryan D, Crouch, DO STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 04:00 AM CERTIFICATE OF DEATH 5a. AGE - Last Birthday Sb. UN (Yrs.) 10b. NAME OF SPOUSE (First, Mildred Shipman 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Rachel Bean 14a. INFORMANT -NAME Patti Kier Katie M. Smydra 16d. CEMETERY, CREMATORY OR OTHER LOCATION 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined CITY/TOWN MOS. 92 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient © ER/Outpatient ❑ JOA 9c. CttY OR TOWN Grand Island DER 1 YEAR DAYS HOURS 16b. LICENSE NO. 1454 CITY / TOWN 21b. IF TRANSPORTATION 0 Driver /Operator ❑ Passenger ❑ Pedestrian Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES lil NO 0 PROBABLY ❑ UNKNOWN ❑ YES IE NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a. REGISTRARS SIGNATURE J 6 - pz- 2. SEX Male 5c. UNDER 1 DAY MINS. OTHER El Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall e. APT. NO. 9f. ZIP CODE 68803 Middle, Last, Suffix) If wife, give maiden name Red Cloud CAUSE OF DEATH (See instructions and examples) 1S. PART 1. 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 ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter oely one causes on a line, Add additional lines if necessary. IMMEDIATE CAUSE: a) Pneumonia 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. STATE INJURY 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24b. TIME OF DEATH August 3, 1924 3. DATE OF DEATH (Mo., Day, Yr.) December 11. 2016 6. DATE OF BIRTH (Mo: Day, Yr) ❑ Hospice Facility l 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Friend 16c. DATE (Mo., Day, Yr.) December 17, 2016 STATE Nebraska 17b. Zip Code 68801 APPROXIMATE I NTERVAL onset to death 2 Weeks 2d. ATWORK? ❑ YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. onset to death 2 Vk./e'eks onset to death Chronic onset to deat 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination end /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and. Tide) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NCI ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo. Da December 15, 2016 ZIP CODE