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n r a p�� a z n 7 C=) o o c� 7` m c_n v x c� z� N Ct. rn CD to Q O can :2-" C=) �j m� z r-n "O > W O 3 r D CC) = M W co �r Cil •✓ W O F—• CT I - WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOI FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISV(C -SECT IOkWiWCH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS LOT -- -'37; BLK. -6 CONTINENTAL DATE OF ISSUANCE _ - APR 13 2000 GARDENS UNIT .1, AN A;DD'N T`Ot T CITY OF GRAND ISLAND, HALL ASS1SXANT" *TATPREG/S. AM LINCOLN, NEBRASKA HEALTH AND "AN SE�i►n'iE9 ?9rs%BYf - - — TT COUNTY, NEBRASKA _ STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN -SE .CES FINANCE AND7SUPPORT 20000883 j `� CERTIFICATE OF DEATH 1 DECEDENT - NAME FIRST MIDDLE LAST SEX 3 DATE OF DEATH iirfolttl D +v )earl 6t T Yi Alfred F Husen Male Aril 6 2000 ._ 4 CITY AND STATE OF BIRTH ill not In USA. name counfryl 5a. AGE - Last Birthday UNDER 1 YEAR UNDER I DAV 6 DATE OF BIRTH !Month. Dav Yearl Grand Island, Nebraska (Yrs) 5b MOS DAYS 79 5c HOURS _� MINIS March 12,__1921 -- h 7 SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH InpaUenl OTHER Nursing -.1— i 508 12 0394 261 PLACE office u9d.Ig e1CPY ;SAl hop farm. HOSPITAL 26g. LOCATION STREET OR R.F D NO. CITY OR TOWN sT4ti Homicide Investtgabon ER Outpatient ® Residence Bb FACILITY -Name 111 not msfitufion, give street and numbed 27a. DATE OF DEATH (Mo.. Day. Yr.) 28a DATE SIGNED (Mo Dav Yr)) 28b TIME OF DEATH DOA F] Other 3032 W College _ 2-06 r - - -- -- --- - - - - -- - - Bc CITY TOWN OR LOCATION OFD TH Bo INSIDE CITY LIMITS 8e COUNTY OF DEATH n 2 27d. To the best of my knowledge. death occurr all el dal a � and due to me ° ° ° 28e. On the basis of ex aminannn arts nr 1 ^.w. rte -. n my p ,on r1ea�� n..erreu -- -- -t f� the Time date and place and oue to the causelsl Stated II Yes [91 No ❑ (Signature and Tnlel 0- --- . - - - -- - 9a RESIDENCE - STATE 9b. COUNTY 9c CITV. TOWN OR LOCATION 9tl. STREET N UM ER llncludirrg LO Code) �iT 9e INSIDE CITY LIMITE Nebraska Hall Grand Island 3032 W. Coll e 68803 Yes R] Np C 10 RACE . (e.g.. While Black. American Indian 11. ANCESTRY (e.IT Italian Mexican. German, elcl 12 ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE dl wife n,ve maiden name) etc.) [Specify) White (Spec+tyl American ❑ NEVER DIVORCED Georgians Bohnart VYl l MARRI _. 14a. USUAL OCCUPATION IG,ve kind o(work done during most 14b. KIND OF BUSINESS INDUSTRY 15 EDUCATION (Speedy only highest grade Completed) of working life, even of refired) Fanner Elementary or Second 10 121 College 1 4 n. 16 FATHER - NAME FIRST MIDDLE LA T MIDDLE MAIDEN SURNAME Henry J. �Iusen NMI Marth 18 WAS DECEASED EVER IN US ARMED FORCES? 19a INFORMANT NAME )Yes no or unk.I (11 yes. give war and dales of services) WWII Georgiann Husen 199/115 07 / q — - - - -_— M ILIN DDR SS - E ��Wesn R R.F D NO.. CITV OR TOWN. STATE ZIP) t College-, Grand Island, Nebraska 68803 _ 120 EMBALMER- SIGNNA�T LICENSE NO 21a METHOD OF DISPOSITION j 21b DATE 21c CEMETERY ORCREMATnORY NAME „ULR.,E.B Bunal Removal A c Crematio:2�ery Not Embalmed 22a. FUNERAL HOME NAME L, .NE ltd EMETERV OR rgEMATORV LOCATION CITY OR TOWN STATE Kleine Funeral Home Cremation Gibbon Nebraska 22b. FUNERAL HOME ADDRESS (STRFE I OR R.F.D. NO_ CITV OR TOWN STATE, ZIP) 3213 W North Front St., Grand Island, Nebraska 68803 123 IMMEDIATE CAUSE 1 (ENTER ONLY ONE CAUSE PER LINE FOR ial. Ibl. AND )cp 1 mervaloetveenpnse. a; F PART 6-4 - ,;, Jy(/ ,at Inter,al between -10 I'll Isar DUE TO. OR AS A CONSEQUENCE OFJ/ rot _ __ �LA !� DJE TO.OR AS A CONSEQUENCE (* -- _ -- - - -' —� Inter v.ti heI en nnsel unr, n..,�� )C) QTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death out not related PART — PART III IF FEMALE. WAS THERE A 24 AUTOPSY PREGNANCY IN THE PAST 3 MONTHS' 25 WAS CASE REFERRED f0 MEDICAI EXAMINER OR CI)RONEP "' � �� ` �J Yes No 16 G nC.�t r (Ages 10.54) Yes No Ves No _ _. - -- 26a 26b. DATE OF INJURY (Mo. Day. Yr.l 26C HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident 0 Undetermined ! [ M Suicide � Pending 26e. INJUR AT WORK 261 PLACE office u9d.Ig e1CPY ;SAl hop farm. street factory 26g. LOCATION STREET OR R.F D NO. CITY OR TOWN sT4ti Homicide Investtgabon 27a. DATE OF DEATH (Mo.. Day. Yr.) 28a DATE SIGNED (Mo Dav Yr)) 28b TIME OF DEATH z Loo0 a -= M_ H 27b DATE SIGNED (Mo. Day Yr) 27c. TIME OF DEATH $ r ° 28c PRONOUNCED DEAD Mo Day, Yr.) 28tl. PRONOUNCED DEAD Mnw' 2-06 r g z _ n 2 27d. To the best of my knowledge. death occurr all el dal a � and due to me ° ° ° 28e. On the basis of ex aminannn arts nr 1 ^.w. rte -. n my p ,on r1ea�� n..erreu -- -- -t f� the Time date and place and oue to the causelsl Stated causel5l Slated. (Signature and Title) ► C. (Signature and Tnlel 0- --- . - - - -- - 29. DID TOBACCO USE CONTRIBUTE TO THE DE THn a AS ORGAN OR TISSUE DONATION BEEN CONSIDERED'/ 30.1b WAS CONSENT GRANTED' [�KYES F] NO El UNKNOWN YES NO YES 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTO^^RNIEVI "' w Pr!ntL � �� /L/J�� Ga� L. off C Zr►�a w �c�lP 32a REGISTRAR 320 DATE FILED BY REGISTRAR (Mo. Day Yr) J APR 12 2000 -