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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 OF ISSUANCE
<br />7/25/2019
<br />LINCOLN, NEBRASKA
<br />ti
<br />1
<br />1
<br />1. DECEDENTS -NAME (First, Wadi',
<br />Darlene Agnes Jensen
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF [FIRTH
<br />202000683
<br />RUSSELL FOSSLEIt
<br />ASSISTANT STATE REG1Si'(RAR
<br />DEPARTMENT OF HEALTH
<br />AAIB 1-LUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH ANB HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Leat, Suffix)
<br />Grand Island N brask
<br />7. SOCIAL SECURITY NUMBER
<br />0=x64.2524
<br />5a. AME - Last 131rthd1*y
<br />(Yrs.►
<br />59. UNDER:1 YEAR
<br />2. SEX
<br />Female
<br />8c. UNDER 1 PAY
<br />mOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Pay, Yr.)
<br />fly 9, 2019
<br />5. DATE OF BIRTH (Mo., Day, Yr4
<br />Jul 20 1941
<br />Sb. FACILITY -NAME (Knot Institution, give street and number)
<br />Wedgewood Care Center
<br />8c. CITY OR TOWN OF DEATH (Include zip coda)
<br />Grand, Is!and 68803
<br />9e REEKTENCE•$TATE 8b. COUNTY
<br />Nebraska _ Hall
<br />9d. STREET AND NUMBER
<br />651 Memorial Dr.
<br />10a. MARITAL STATUS AT TIME OF DEATH Il Married 0 Never Married
<br />0 Married but separated 0 Widowed [a Divorced Q Unknown
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />C) ER/Outpatient
<br />DOA
<br />9c. CITY OR TOW
<br />Gran !Siertd
<br />OTHER ® Nursing Home/LTC
<br />0 Decedent's Home
<br />Other (Specify)
<br />❑ Hospice Facility
<br />. APT. NO. 9f. ZIP CODE
<br />1
<br />99, INSIDE CITY UMTS'
<br />® vas ■ NQ
<br />11. FATHOM -NAME (First, Middle, Last. Suffix)
<br />Arnold RoeDker
<br />ti. EVER IN UM. ARMED FORCES? Give dates of service if Yes.
<br />(Yss, P1o, *r Unk.) NO
<br />10b, NAME OF SPOUSE (FIrHt, Middle, Last,
<br />Kenneth Jansen
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Agnes Wissing
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />14e. INPORMANT•NAME
<br />KonnetFl. Jansen
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />lSb. LICENSE NO.
<br />14b. RELATIONSHIP TQ DECEDENT
<br />Seouse
<br />tae. DATE (Mo., Day, Yr.)
<br />CITY / TOWN
<br />Gibbon
<br />Jul 19, 2019
<br />STATE
<br />Nebraska
<br />7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, atoll
<br />Curran Funeral Chapel, 3005 S. Locust 8t,. Grand Island. Nebraska
<br />17b, Zip: Code
<br />68801
<br />CAUSE QF DE4T4 (S@e (natruc;Ignk anc4 examglgJ
<br />PAtIVI. tinter the ghaln ar ed9Ms• -diseases, Injuries, or compllcationedhat directly ceuaed tits death. 00 NOT tinterterminel events such 9s cardiac arrest,
<br />respiretary arrest, or vemrici lar nbriiiation without showing the stlalegy. DO NOT ABBREVIATE. Enter only one cause Ona lino. Add additional lines N mammary.
<br />IMMEDIATE CAUSE (Final
<br />dleeses or condition inuaina
<br />In;desthl
<br />SagltatttialI t bat conditions, if
<br />any, tyditte to the elmae hilted3
<br />On linea _._. _..
<br />Enter the UNDERLYING CAUSE
<br />Mieease or injury that Inithaed?
<br />the events moulting -in death)
<br />LAST;
<br />IMMEDIATE CAUSE:
<br />a) Respiratory Failure
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />< 1 Week
<br />DUE TO, OR A8 A CONSEQUENCE OF:
<br />b) Encephalopathy
<br />DUE TO, OR AS A . ONSlQUENGE OF:
<br />0)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART 11.OTHER SIGNIFICANT CONDITIONS -Conditions contrIbudng to the death but net resulting in the underlying cause given in PART!.
<br />History Of Subdural Hematoma, History Of Lymphoma
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />z
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at INRs of depth
<br />❑
<br />Not Mesnenti hid meaner* within 41 days or death
<br />0 NM proMMIS,1t9 Imminent el lees tot 999r before death
<br />❑ Unknown If pf a$0I) *Whim east emir
<br />22a. DATE OF INJURY (Me„ Day, Yr.
<br />22d. INJURY AT WQRKT.
<br />[jNIS ONO
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />21e. MANNER OF D2ATH
<br />EN.... 0
<br />0 Accident 0 Pendine Investigation
<br />0 Suicide 0 CoulJ' apt be determined
<br />226. TIME OF INJURY
<br />Q1tb-�,1IF TRANSPORTATION INJURY
<br />4 utHaiishivaiw
<br />0 ?kdaStnan
<br />0 fatter 101Weifv)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />21d. WERE AUTOPSY FUNDINGS AVAILABLE
<br />TO COMPLSTE CAUSE OF DEATH?
<br />0jYES 0 N
<br />22c, PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Spsclfy)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />22a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 18, 2019
<br />b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Julv 23. 2019 03:14 AM
<br />.o
<br />ed. To 1M best of my knowledge, death occurred at the time, date and place
<br />and due to the csuseUl elated, (SIgnature and T1tle)
<br />Jennifer L Brown, MD
<br />244. DATE
<br />SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED
<br />DEAD
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />the time, date and piece and due to the 1990019) stated. (Signature and TRIO)
<br />5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TI DONATION BEEN CONSIDERED?
<br />0 YES 61 NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 17 +
<br />27. NAME, TITLE AND ADORES$ OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />THE. -REGISTRAR'$ SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 2S0 Is NO 0 YES 0 NO
<br />286. DATE FILED BY REGISTRAR.(M
<br />July 23, 2019
<br />
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