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<br />y STATE OF NEBRASKA 7
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISSUANCE
<br />413/2019
<br />LINCOLN, NEBRASKA
<br />w
<br />a.
<br />c
<br />201905876
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Maylon John Hanson
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Aurora, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />88
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 29, 2019
<br />6. DATE OF BIRTH (MO., Day, Yr.)
<br />November 25, 1930
<br />7. SOCIAL SECURITY NUMBER
<br />507-36-3563
<br />8b. FACILITY -NAME (It not. Institution, give street and number)
<br />Veterans Affairs Medical Center
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />❑; ER/Outpatient
<br />❑I DOA
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island, 68803
<br />9a RESIDENCE -STATE
<br />Nebraska ;
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND NUMBER
<br />1917 Stolley Park Circle
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />I YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ®Married 0 Never Married
<br />0 Married, but separated 0 YAdowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Paul Hanson
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Karen Simmerman
<br />1 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Julia Shaneyfelt
<br />13. EVER IN U.S ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes :02/13/1952-02/13/1954
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Karen Hanson
<br />16a. EMBALMER -SIGNATURE
<br />Mike McQuiston
<br />16b. LICENSE NO.
<br />1129
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />April 3, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Aurora Cemetery Aurora
<br />STATE
<br />Nebraska
<br />affect the estate of the deceased are filed w
<br />E
<br />L
<br />v
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Hiabv McQuiston Mortuary. Inc.. 1404 L Street. PO Box 204. Aurora. Nebraska
<br />17b. 2Ip Code
<br />68818
<br />CAUSE OF DEATH (See instructions and examples)
<br />/a. PART I. Enter the chain of everts- -diseases, injuries, or complications -that directly caused the death. DO NOTentertenninal events such as cardiac arrest,
<br />respiratory arrest or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Metastatic Lung Cancer Unknown Type
<br />disease or condition resulting
<br />in death)
<br />Sequentially fist conditions, S
<br />any, feeding lathe cause fisted
<br />on line a
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />One Month
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(*teats or injury that initiated
<br />rite events re#ultigp-.In death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />onset to death,
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Coronary Artery Disease,
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />'❑ Net pregnant, b,4. pregnant 4.1. days to 1 year before death
<br />❑ tit kndied if pregnant *Mee' the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b, IF. TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />El Other{Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />DYES NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO.
<br />I
<br />tL _.
<br />234. DATE OP DEATH (Mo., Day, Yr.)
<br />March 29, 2019
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />March 30, 2019 10:00 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />Shawn S. Lawrence, MD
<br />25. DO TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(%) stated. (Signature and TM)
<br />26a. HAS ORGAN OR TISSUE • • ATION BEEN CONSIDERED?
<br />❑ YES 7 •
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Shawn S. Lawrence, MD, 2201 N Broadwell Ave., Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE d
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 1, 2019
<br />
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