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, m STATE OF NEBRASKA r1tA� \ 4 N," YY 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 201804277 4/23/2018 LINCOLN, NEBRASKA STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH • a I ct i 8c. CITY OR TOWN OF DEATH (Include Zip Code) 0 Kearney 68847. g 9a. RESIDENCE -STATE Nebraska LL a 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married LI Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S:NAME (First, Middle, Last, Suffix) 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Albert Mervin Hansen 4. CITY: AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Howard CO linty, Nebraska 7. SOCIAL SECURITY NUMBER 508 -32 -6530 Sb. FACILITY -NAME Of not Institution, give street and number) Weloov Assisted Living at Kearney 9d. STREETANONUMBER 5616 4th Avenue Albert M Hansen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, NO, or link.) Yes 01/18/1952-05/06/1952 15. METHOD OF I;IISPQStTION E Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal >0 Other (Specify) 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant,; but pregnant within 42 days of death ❑ Not pregnant, tint ptegnant.43 days to 1 year before death ❑ Unknown if pregnard within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? AYES ❑NO' 23a. DATE OF DEATH (Mo., Day, Yr.) April 13, 2018 A' ffl 'a d 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH I u z April 13, 2018 05:35 AM 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 N and due to the cause(s) stated. (Signature and Title) F W Isaac J. Bert(, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? LI ❑ NO ❑ PROBABLY ❑ UNKNOWN 8a. REGIST Slta 9b. COUNTY Buffalo (Yrs.) 89 5a. AGE - Last Birthday 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Kearney 16a. EMBALMER - SIGNATURE Mark McBride DAYS HOURS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient O ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home E Other (SpecifyYkSSISTED LIVING Hospice Facility 8d. COUNTY OF DEATH Buffalo 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY MINS. 9f. ZIP CODE 68847 14a. INFORMANT-NAME Ted E Hansen 16 b. LICENSE NO. 1199 3. DATE OF DEATH (Mo., Day, Yr.) April 13, 2018 February 7, 1929 6. DATE OF BIRTH (Mo., Day, Yr.) 9g. INSIDE CITY' LIMITS E YES ❑ NO lob. NAME OF SPOUSE (First, , Middle, Last, Suffix) If wife, give maiden name Bonnie Mae Jepson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Stella Frederiksen 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day, Yr.) April 17, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION Elmwood Cemetery CITY / TOWN St. Paul STATE Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS ( Street, City or Town State) Apfei Funeral Home. 1123 W. 2nd. Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1a. PART I. Enter the chein of events- -diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, • respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause op a line. Add additional lines N necessary. IMMEDIATE CAUSE: a) Respiratory Failure IMMEDIATE CAUSE (Final disease or condition resuhing in deatid • Sequentially list conditions, if any, leading to the cause Iiyted'- on line a. Enter the UNDERLYING CAUSE (disease or in jury that inl00ed the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: b) Congestive Heart Failure DUE TO, OR AS A CONSEQUENCE OF: c)Aortic Stenosis DUE TO, OR AS A CONSEQUENCE OF: d) APPROXIMATE INTERVAL onset to death 1 Day onset to death 5 YearS onset to death 3 Years onset to death 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Renal Failure ;< <. 22b. TIME OF INJURY 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 0 Suicide ❑ Could not be detemnned 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES ENO 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES N bp O 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 2 NATURE /(_ �/�_,,. z,- ■ 28b. DATE FILED BY REGISTRAR (MO.,`Day, Yr.) April 19, 2018