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Thu STATE OF NEBRASKA w w v Q E 0 O 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Larry Lamont Hansen MD 4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Paul, Nebraska 7. SOCIAL SECURITY NUMBER 505 -74 -7366 . FACILITY -NAME (If not Institution, give street and number) Lake East Of 2860 W. Bismark 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 9a. RESIDENCE-STATE 9b. COUNTY Nebraska Hall 9d. STREET AND NUMBER 2711 Cottonwood Rd 1Qa. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated; ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (Fl , Middle, Last, Suffix) Raymond Carl Hansen 13. EVER IN U.S. ARMED; FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation Cremation ❑ Entombment ❑ ❑ Other (Specify) 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska Sequentially list COnditiOns, if any leading to the CAUSE. listed on line a. - Enter the UNDERLYING CAUSE glisealiq or injury that initiatett::: .... .--- r-.. ........ __...... the events resulting in death) t.AsT 20. IF' FEMALE: ❑ Not pregnant within past year Pregnant at time of death ❑ Not pregnarq.,ixut pregnant within 42 days of death tJ3n pregnant,;but pregnalt 4T. days tot year before death D°°' if Pteynard 'Mthinihe past year 22a. DATE OF INJURY (Mo., Day, Yr.) March 5, 2017 22d. If iJURY ATWORK? OYES ZINO 22f. LOCATION OF INJURY - STREETS NUMBER, APT.NO. Lake East Of 2860 E. Bismark, Grand Island 23a. DATE OF DEATH (Mo., Day, Yr.) d n W J 0 u < C! S Y p c 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 3/21/2017 LINCOLN, NEBRASKA 23b. DATE SIIaNIED (Mo., Day, Yr.) • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 14a. INFORMANT- NAME Carol Ann Hansen 16a. EMBALMER - SIGNATURE Not Embalmed DUE TO, OR AS A CONSEQUENCE OF: b)Gunshot Wound To Head DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 21a. MANNER OF DEATH ❑ Natural ❑ Homicide ❑ Accident ❑ Pending Investigation E Suicide ❑ Coulo pot be determined Unknown Lake 22e. DESCRIBE HOW INJURY OCCURRED Decdent in lake had contact wound to left temple. 23c. TIME OF DEATH d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 201'702844 50. AGE - Last Birthday Sb. UNDER 1 YEAR (Yrs.) MOS. 59 CITY /TOWN 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient 0 ERlOutpatient ❑ Decedent's Home ❑ DOA ® Other (Specify)Lake East of 2360 W, 13iamark 8d. COUNTY OF DEATH Hall 9c. CITY' OR TOWN Grand Island DAYS 19e. APT. NO. b. LICENSE NO. Central Nebraska Cremation Services Gibbon ❑ Pedestrian 0 Other (Specify) 2. SEX Male 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Nebraska 24a. DATE SIGNED (Mo., Day, Yr.) March 6, 2017 HOURS 5c. UNDER 1 DAY MINS. 9f. ZIP CODE 68801 18. PART IL' OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES OTHER ❑ Nursing Home /LTC 6. DATE OF BIRTH (Mo., Day, Yr.) May 15,1957 lob. NAME OF SPOUSE (First, > Middle, Last, Suffix) if wife, give maiden name Carol Ann ! Knuth 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Nora Sorensen March 5, 2017 10:57 PM 17 03445 3. DATE OF DEATH (Mo., Day, Yr.) March 5, 2017 © Hospice Facility 9g. INSIDE CITY LIMITS' ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day; Yr.) March 9, 2017 STATE Nebraska 17b, Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 8. PART 1. Enter the chair) Of events -- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause' en a fine, Add additional lines if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Penetration Brain Injury Immediate disease or condition resulting ath) . ___ . onset to >deatti:: Immediate onset to death 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24e. On the basis of examination and /or investiga ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) S. Alex West, Hall Deputy County Attorney 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Driver /Operator 0 YES 2 NO ❑ Passenger 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSEOF DEATH7 ❑ YES [] No ZIP CODE 68801 24b. TIME OF DEATH Approx. 05:00 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED? NO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEE ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN ❑ YES El NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print S, Alex West, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 I 28a. REGISTRAR'S SIQNATURE 28b. DATE FILED BY REGISTRAR (Ma, Day, Yr.) March 15, 2017 CONSIDERED? Not Applicable if 26a is NO ❑ YES ❑ ktvie