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STATE OF NEBRASKA 1- W U 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 2/8/2018 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix Roger Eugene Jensen 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Paul, Nebraska' 7. SOCIAL SECURITY NUMBER 508 -48 -1473 86. FACILITY -NAME (lf not Institution, give street and number) Park Place A Golden Living Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 6.8803 9a. RESIDENCE•STATE 9b. COUNTY Nebraska Hall 9d. STREET AND NUMBER 1516 North Lafayette 1Oa. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑;Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S-NAME. (First, Middle, Last, Suffix) Elmer Jensen 13. EVER IN U.S . ARMED FORCES? Give dates of service if Yes. (Yes, No, or Urtk.) NO 15. METHOD OF DISPOSITION E Burlal ❑ Donation Chris McCoy ❑ Cremation ❑ Entombment ❑Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska CAUSE OF DFATH (See instructions and examples) 15. PART I. Enter the: Chain of events- -diseases, injuries, or complications -that directly caused the death DO NOT enter tenminal- events such as cardiac arrest, respiratory arrest, or Ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Failure To Thrive to deatttl SgwentiallsOist dblldihons, (! any, leading to the cause •bsted on line a ... Enter the UNDERLYING CAUSE (disease or injury that initiated the events eesuking -in death) LAST 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Parkinsons Disease, Aspiration Pneumonia 20. If FEMALE; ❑ Not 'pregnant Within past year ❑ Pregnant at time of death ❑ Nit1 pregnant, but pregnant within 42 days of death © Not pregnant, but pregnant 43 days to 1 year before death ❑ unknown it pregnant within the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 a 22d, INJURY AT .WORK? :: >. 22e. DESCRIBE HOW INJURY OCCURRED DYES ❑NO 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) ai January 31 2018 1 z r 23b. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH o I d z February 2, 2018 04:30 AM a 0 3d. To the best of my knowledge, death occurred at the time, date and place 8 c and due to the cause(s) stated. (Signature and Title) Ryan D Crouch, DO 28a, REGISTRAR'S SIGNATURE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 16a. EMBALMER- SIGNATURE DUE TO, OR AS A CONSEQUENCE OF: b) Dementia DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 201803349 5a. AGE - Last Birthday (Yrs.) 79 14a. INFORMANT -NAME Connie Joy Jensen 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park Cemetery 21a. MANNER Of DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Cou 4 not be determined CITY/TOWN J� i 8a. PLACE OF DEATH HOSPITAL ❑ inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island 106, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Connie Joy Spilper 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lena Robinson 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 5b. UNDER 1 YEAR MOS. DAYS STANLEY COOPER ASSISTA � STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 9e. APT. NO. 1191 2. SEX Male HOURS 8d. COUNTY OF DEATH Hall 16b. LICENSE NO. 5c. UNDER 1 DAY OTHER E Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) CITY / TOWN Grand Island MINS. 24a' DATE: SIGNED (Mo., Day, Yr.) 9f. ZIP CODE 68803 216. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian Other (Specify) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 3. DATE OF DEATH (Mo., Day, Yr.) January 31, 2018 September 15, 1938 16c. DATE (Mo Day, Yr) February 3, 2018 18 01444 STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the Oasis 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) 28b. DATE FILED BY REGISTRAR (MO; Day, Yr,) February 5, 2018 6. DATE OF BIRTH (Mo., Day, Yr.) 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse STATE Nebrasi a 17b.2ap Code 68801 APPROXIMATE INTERVAL onsettodeath 6 Months onsettodeat Chronic ❑ Hospice Facility onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAtLABLE TO COMPLETE CAUSE OF DEATH? 0 YES ❑NO ite, etc. (Specify) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO