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<br />STATE OF NEBRASKA
<br />WWIEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF WAIT AdQ((Q h%SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEI! p j?EiR7OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR •V.FTA Ir D (,(
<br />DATE OF ISSUANCE
<br />06/06/2013
<br />LINCOLN, NEBRASKA
<br />STATE
<br />202005631
<br />yea ,_ri i✓
<br />`rSTAN
<br />�4SSI3J 11 Stlit REtI$TR 1R
<br />DDPARTMENT OF HEALT 4A, iO
<br />IMMA4 5ERVIC $ Ir •' >
<br />OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN 9ERVft S•. ` 1•
<br />' ' ; `` 1y -°a
<br />CERTIFICATE OF DEATH 1; ; I„ +-`' .�•
<br />13 02429
<br />To be completed/verified by: FUNERAL DIRECTOR 1
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Sharon Mauveen Hanssen
<br />2. SEX < G " -.
<br />Female
<br />341tAt OF DEATH (Mo., Day, Yr.)
<br />June 1, 2013
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />Sb. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(YR•)
<br />80
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />December 7, 1932
<br />7. SOCIAL SECURITY NUMBER
<br />507-34-5063
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 inpatient OTHER IXI Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (tf not Institution, give street and number)
<br />Golden LivingCenter-Grand Island Lakeview
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />ga. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />3715 South Blaine Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />0 YES IXI NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, last, Suffix) H wife, give maiden name
<br />Willis John Hanssen
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Arthur Sanders
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Violet Reed
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unit.) No
<br />14a. INFORMANT -NAME
<br />Willis John Hanssen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />June 3, 2013
<br />® Cremation ❑Entombment
<br />❑ Removal 0 Other (Specify)
<br />lid. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />re
<br />T.T.
<br />F
<br />C2
<br />E
<br />8
<br />E
<br />H
<br />IL PART I. Enter the rbiD of events. diseases, I.Autss, or compilations -hat directly quad the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing Me etiology. DO NOT ABBREVIATE. Enter only one muse on a nine. Add additional lines H necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Cor Pulmonale
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Years
<br />In assns) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, s b)Severe Pulmonary Hypertension
<br />any, leading to the cause listed
<br />line
<br />onset to death
<br />Years
<br />an a. DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Severe chronic obstructive pulmonary disease
<br />(disease or Injury that Initiated
<br />onset to death
<br />Years
<br />the events resulting 1n aeatht DUE TO, OR AS A CONSEQUENCE OF:
<br />`AST d)Tobacco Abuse
<br />onset to death
<br />Years
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />Obstructive Sleep Apnea, History Of CVA, Hypertension, Hyperlipidemia, Hypothyroidism
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pr.gnant n time a death
<br />21a. MANNER OF DEATH
<br />tEl Natural 0 Homicide
<br />0 Accident 0 Penang inveatlgation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑Pas°^
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ® NO
<br />0 N Pregnant, but pregnant wadn 42 days of deathElSui
<br />0 Not pregnant, but pregnane 43 days to 1 mar before doSuicidem
<br />0 Unknown if pregnant within the past year
<br />❑ Could not determined
<br />❑ Pedestrian
<br />Other (Specify)
<br />21d.TO COMPLETE CAUSE OWERE AUTOPSY F DEATH? AVNIABLE
<br />TO
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />B
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 1, 2013
<br />L
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 3, 2013
<br />23c. TIME OF DEATH
<br />07:35 PM
<br /><'
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />g . To the best of my l mowldge, death occurred at the time, date and Placa
<br />s and due to the cause(s) stated. (Signature and TIN)
<br />Jay C. Anderson, MD
<br />(
<br />E
<br />fN. On the basis of examinatlon and/or Investigation, In my oplolon death occurred at
<br />the arse. date and place and due to the cause(s) stated. (Signature and Tills)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR
<br />® YES 0 NO 0 PROBABLY 0 UNKNOWN ❑ YES
<br />ISSUE DONATION BEEN CONSIDERED?
<br />IXI NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 8803
<br />28a. REGISTRAR'S SIGNATURE 4 {/
<br />r
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 5, 2013
<br />
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