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<br />1\\.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOO -ONF_ ILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SE-CTIM WNICFPIIS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE 200107604
<br />�II,�%J1IVEF`S.QOpEI_
<br />MAR 12001 ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE -AN SUPPORT
<br />AL STATISTICS
<br />CFRTTFT ('ATF CIF nFATH - 01847
<br />— -
<br />1 DECEDENT -NAME FIRST MIDDLE LAST
<br />-
<br />2—SEX
<br />7"b'AT�OF DEATH IMw1tn Dav Year)
<br />Merle Harvey Christensen
<br />Male °
<br />February 18 2001_____
<br />A. CITY AND STATE OF BIRTH /lf not ih US.A.. name country/
<br />AGE - Last Binhday
<br />M
<br />UNDER I DAY 1
<br />1 6. DATE OF BIRTH IMOnth. Dav Yearl
<br />Sb MOS. I DAYS
<br />Sc. HOURS MINS
<br />�1,
<br />Farwell, Nebraska
<br />(Vrsl
<br />72
<br />January 10 1929 _
<br />7-SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />HOSPITAL. OTHER Nursing Ho
<br />❑ In F1 me
<br />507
<br />s h
<br />-24 -3757
<br />❑ ER Outpatient ❑ Residence
<br />FACILITY Name lit not institution, give street and number)
<br />O
<br />❑ DOA �Other(Soei N1 Skilled Care
<br />St. Francis Skilled Care Unit
<br />-
<br />8c. CITY. TOWN OR LOCATION OF DEATH Bd INSIDE CITY LIMITS Be. COUNTY OF DEATH
<br />Grand Island Yes 0 No E] Hall
<br />_ _
<br />Zip v;o,iei e NJUL'r :[OiTS
<br />da RES106ME -SIAtE Igo COUNTY -9c CITV.- -TOWN OR LOCATION 90. STREET AND NUMBER Iwfuding G
<br />Ave.
<br />Nebraska Hall Grand Island 814 N. Custer, 68803 Yes ❑X ND ❑
<br />10 RACE - (e.g.. While. Black. American Indian.
<br />"•
<br />C) 4
<br />13 NAME OF SPOUSE Ill wife give maiden Hamel
<br />etc.( (Specify(
<br />ISpeatvl
<br />American
<br />NEVER DIVORCED
<br />❑
<br />Jeannine Fuller
<br />White
<br />MARBLED
<br />- - - --
<br />10a. USUAL OCCUPATION IGrve kinder work done during most
<br />O
<br />CTJ
<br />Speoty only n.ghest grade completed)
<br />Elementary or Secondary 10 121 College 1
<br />9th Grade
<br />of working life, even it retired)
<br />Fire Hydrant Supervisor
<br />a
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Fri
<br />Mildred 1I -TI Harvey - - -- -
<br />©
<br />Ives. no. or uri (it yes give war aril dates of services Jeannine Christensen
<br />1
<br />Yes 02/02/1950 - 03%16/1953
<br />r 19b. INFORMANT MAILING ADDRESS iSTREET OR R F D NO CITY OR TOWN STATE ZIPI
<br />814 N. Custer Ave., Grand Island, Nebraska 68803
<br />I
<br />21a METHOD OF DISPOSITION
<br />21 b. DATE 21c CEMETERY OR CREMaTr -jDr NAMEC'eteT^X7
<br />the time, and place and
<br />, (Signature and Title) ►
<br />hP
<br />30.a HAS ORGAN OR TISSUE DO ON CONSIDERED'
<br />p Tt
<br />O
<br />Y22aUNERiAL HOME -NAME
<br />2 1d. CEMETERY OR CREMATORY LOCATION CITV r)k. TOWN STATi
<br />ine Funeral Home
<br />❑ C'ema " °" ❑ ° ° °� ° °`
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R D. NO CITY OR TOWN. STATE, ZIP)
<br />3213 W. North Front Street Grand Island Nebraska 68803
<br />IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR Ial. (b). AND Ic)I Inte—1 Detween onset nnc ss11r
<br />CD
<br />DUE TO, OR AS A CONSEQUENCE OF Inge —I between onset no aealn
<br />(blsevere end stage COPD approx. 10 years_
<br />Q
<br />r�A
<br />M
<br />p
<br />Cn
<br />rn n
<br />'D F
<br />Z3
<br />r =�
<br />o
<br />rn
<br />b
<br />►-'
<br />ct,
<br />-�
<br />N
<br />0
<br />LOT THREE (3), in
<br />BLOCK EIGHT (8), IN
<br />WEST VIEW
<br />ADDITION TO
<br />THE CITY
<br />OF
<br />GRAND ISLAND, HALL
<br />COUNTY,
<br />NEBRASKA
<br />1\\.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOO -ONF_ ILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SE-CTIM WNICFPIIS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE 200107604
<br />�II,�%J1IVEF`S.QOpEI_
<br />MAR 12001 ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE -AN SUPPORT
<br />AL STATISTICS
<br />CFRTTFT ('ATF CIF nFATH - 01847
<br />— -
<br />1 DECEDENT -NAME FIRST MIDDLE LAST
<br />-
<br />2—SEX
<br />7"b'AT�OF DEATH IMw1tn Dav Year)
<br />Merle Harvey Christensen
<br />Male °
<br />February 18 2001_____
<br />A. CITY AND STATE OF BIRTH /lf not ih US.A.. name country/
<br />AGE - Last Binhday
<br />UNDER 1 YEAR
<br />UNDER I DAY 1
<br />1 6. DATE OF BIRTH IMOnth. Dav Yearl
<br />Sb MOS. I DAYS
<br />Sc. HOURS MINS
<br />�1,
<br />Farwell, Nebraska
<br />(Vrsl
<br />72
<br />January 10 1929 _
<br />7-SOCIAL SECURITY NUMBER
<br />8a. PLACE OF DEATH
<br />HOSPITAL. OTHER Nursing Ho
<br />❑ In F1 me
<br />507
<br />pa—
<br />-- --
<br />-24 -3757
<br />❑ ER Outpatient ❑ Residence
<br />FACILITY Name lit not institution, give street and number)
<br />Bb. -
<br />❑ DOA �Other(Soei N1 Skilled Care
<br />St. Francis Skilled Care Unit
<br />-
<br />8c. CITY. TOWN OR LOCATION OF DEATH Bd INSIDE CITY LIMITS Be. COUNTY OF DEATH
<br />Grand Island Yes 0 No E] Hall
<br />_ _
<br />Zip v;o,iei e NJUL'r :[OiTS
<br />da RES106ME -SIAtE Igo COUNTY -9c CITV.- -TOWN OR LOCATION 90. STREET AND NUMBER Iwfuding G
<br />Ave.
<br />Nebraska Hall Grand Island 814 N. Custer, 68803 Yes ❑X ND ❑
<br />10 RACE - (e.g.. While. Black. American Indian.
<br />1 t. ANCESTRY le g Italian. Mexican. German, etcl
<br />t 2.� MARRIED ❑WIDOWED
<br />13 NAME OF SPOUSE Ill wife give maiden Hamel
<br />etc.( (Specify(
<br />ISpeatvl
<br />American
<br />NEVER DIVORCED
<br />❑
<br />Jeannine Fuller
<br />White
<br />MARBLED
<br />- - - --
<br />10a. USUAL OCCUPATION IGrve kinder work done during most
<br />1 ab KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION
<br />Speoty only n.ghest grade completed)
<br />Elementary or Secondary 10 121 College 1
<br />9th Grade
<br />of working life, even it retired)
<br />Fire Hydrant Supervisor
<br />City
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Arthur B. Christensen
<br />Mildred 1I -TI Harvey - - -- -
<br />18 WAS DECEASED EVER IN US ARMED FORCES' Korean 19, INFORMANT NAME
<br />Ives. no. or uri (it yes give war aril dates of services Jeannine Christensen
<br />1
<br />Yes 02/02/1950 - 03%16/1953
<br />r 19b. INFORMANT MAILING ADDRESS iSTREET OR R F D NO CITY OR TOWN STATE ZIPI
<br />814 N. Custer Ave., Grand Island, Nebraska 68803
<br />ER- SIGNAT EBLICENSE
<br />21a METHOD OF DISPOSITION
<br />21 b. DATE 21c CEMETERY OR CREMaTr -jDr NAMEC'eteT^X7
<br />the time, and place and
<br />, (Signature and Title) ►
<br />Feb. 22, 2001 Westlawn Memorial Park
<br />30.a HAS ORGAN OR TISSUE DO ON CONSIDERED'
<br />Burial ❑ RemDVal
<br />I
<br />Y22aUNERiAL HOME -NAME
<br />2 1d. CEMETERY OR CREMATORY LOCATION CITV r)k. TOWN STATi
<br />ine Funeral Home
<br />❑ C'ema " °" ❑ ° ° °� ° °`
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R D. NO CITY OR TOWN. STATE, ZIP)
<br />3213 W. North Front Street Grand Island Nebraska 68803
<br />IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR Ial. (b). AND Ic)I Inte—1 Detween onset nnc ss11r
<br />\PART
<br />I(a)respiratory failure months _
<br />DUE TO, OR AS A CONSEQUENCE OF Inge —I between onset no aealn
<br />(blsevere end stage COPD approx. 10 years_
<br />nnnri SS vpnrc
<br />-
<br />p t I�t�F�g3j iCentliti�n�.•Ln r��Y1e JVI; Pg ILpt r�f�te�r PART
<br />III IF FEMALE, WAS THERE A
<br />AU TOP Sy
<br />2R WAS CASE REFERRED TO MEDICAL
<br />PART J
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'
<br />jPPREGNANCY
<br />" disease, chronic('congestive� heart fa 1A46r
<br />G -5C) Yes No
<br />Yes No
<br />Yes No
<br />26a. i s C emic c
<br />&iTofttg wfya�h�:' Yr.J
<br />26c HOUR OF INJURY
<br />26d DESCRIBE HOW INJURY OCCURRED
<br />F1Accident Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />25t LL INJURY -St ho l Farm_ street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Investigation
<br />❑ ❑
<br />DMIce bu011tll
<br />Homicide
<br />Yes No
<br />a. DATE OF DEATH (MO.. Day Yr.)
<br />28a. DATE SIGNED (MO.. Day Yrl
<br />28b TIME OF DEATH
<br />2 -18 -01
<br />M_
<br />y `r 2'
<br />DATE SIGNED (me Day Yr.)
<br />7�7c TIME OF DE H
<br />28c. PRONOUNCED DEAD (Mo. Day. YO
<br />28d. PRONOUNCED DEAD (How(
<br />ego
<br />2 -21 -0
<br />(
<br />�. a' M
<br />o u
<br />- o
<br />M
<br />o c
<br />a
<br />o o o
<br />d. To the Vest of my kn edge. dea urretl at Ih e, tlat and p c
<br />n d e to the
<br />p8e On the basis of examination and or Investlgauon. In my opinion oealn occurred at
<br />date due to the cause(s) stated.
<br />I cause(s) stated. /
<br />(Signature and Title) ►
<br />/ IY,
<br />�A
<br />the time, and place and
<br />, (Signature and Title) ►
<br />4. DID TOBACCO USE CONTRIBUT 0 THE D TH?
<br />30.a HAS ORGAN OR TISSUE DO ON CONSIDERED'
<br />3� WAS CONSENT GRANTED'
<br />YES ❑ NO UNKNOWN
<br />jBEEEEN
<br />VES IV NO
<br />❑ YES NO —
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY, ITvpe or Print)
<br />Steven 1j HuseU MD, 2116 W Faidley Ave., Grand Island, Nebraska 68803
<br />tsta. Ht�minHn n - X /" I FEB 2 7 2001
<br />
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