202005688 - Laserfiche WebLink

Browse

IIIBIax$ x tBtlkl?ttpiliZiateriiiaaa' Ifii6p8°eaHEN49W1V.,T. c1t 16Apt�iszf nerITIN as4+ fv- .x:::011451111,1": ba@.. WHEN THIS ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 7/23/2020 LINCOLN, NEBRASKA 202005688 let rid;,? <fy-/IF?.ket t*€. SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 20 09454 IPursuant to section 30-2413, demands for notice which may affect the estate of the deceased are Med with the county court in the county where the decedent resided at the time of death, --- - - -- --- - -- -- -- 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Karen Lea Hansen 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) July 15, 2020 4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)'. Chicago, Illinois (Yrs.) 71 MOS. DAYS HOURS MINS. March 1, 1949 7. SOCIAL SECURITY NUMBER 352-42.6617 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility Sb.'FACIUTY-NAME (If not Institution, give street and number) Grand Island Lakeview Care & Rehabilitation Center ❑ ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c, CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 908 S. Vine Street 9e. APT. NO. 9f. ZIP CODE : 68801 9g INSIDE CITY LIMITS to YES 0 NO lea. MARITAL tSTATUS .AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Larry Hansen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Marlin Clyde Christensen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) LaVerne Ann Doran 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, orUnk.) No 14a. INFORMANT -NAME Larry Hansen 14b. RELATFONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Buriai El Donation tid ❑Entombment 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16e. DATE (Mo., Day, Yr.) July 16 2020 Cremation Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State) Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) 1e. PART I. Enter the chain of events- -die , injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE wine' _. a)Subdural Hematoma disease or -condition resulting In death) onset to death 3 Months DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)Trauma any, leading to the cause listed oh line a. onset to death 3 Months DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (dome* or injury that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART (I. OTHERSIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I. Wound Infection, Hypertension, Vascular Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: ®'i Net pregnant within pest year 0 magmaatom. of death 21a. MANNER OF DEATH 0 Natural ❑ Homicide ® Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? -- ❑ YES ®NO D Not pregnant, but pregnant within 42 days of death❑ 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year ❑ Suicide ❑ Could not be determined Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) April 5, 2020 22b. TIME OF INJURY Unknown 22c. PLACE OF INJURY -At home, Home farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ® NO 22e. DESCRIBE HOW INJURY OCCURRED fall at home 23f LOCATION 908 $ OF iNJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE Vine St, Grand Island Nebraska 68801 To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) July 15, 2020 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 22. 2020 23c. TIME OF DEATH 05:03 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD fid. To_nw best ofmy knowledge, death occurred at the time, date and place add due to the'xauea(s) stated. (Signature and Title) Rebecca Steinke, MD 24e. On the basis of enaminatlonand/or Inveetige ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and TMe) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? M YES :❑ NO ;❑ PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO tab. WAS CONSENT GRANTED? Not Applicable If 265 is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Rebecca Steinke, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE �Dc.-4/37-a11-_.#--/11-o4-74.7,- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 22, 2020