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n TO THE CITY OF GRAND ISLAND, HALL COUNTY, NEBRASKA
<br />M
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMMT M- rA ALTH,
<br />IT CERTIFIES THE BELOW TO SEA TRUE COPY OF AN ORIGINAL RECORD ON F /LE if nor S` iTE _
<br />DEPARTMENT OF HEALTH, BUREAU OF V ?AL STATISTICS, WHICH IS THE LEGAL QEPflSMQ -Y FOi
<br />VITAL RECORDS.
<br />ATE Of ISSUANCE � -- -
<br />2 0 010 9 413 STAG r $. CQOm'
<br />FEB 3 1997 ASSISTANT ST44TAMG/$MA1f
<br />LINCOLN, NEBRASKA NEBRASKA DEPARTM &fOF Z*
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />DECEDENT - NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH tMomh. Day . Pearl
<br />Margaret C. Hansen Female January 25, 1997
<br />5a. AGE -Last Birthday UNDER t YEAR UNDER 1 DAV 6. DATE OF BIRTH /Monts. Day Yearl
<br />_. CITY AND STATE OF BIRTH Ill not n U S.A.. name country/ .._..__ � ... -...
<br />I Salt Lake City, Utah
<br />485 -12 -1466
<br />8b. FACILITY - Name lily not rnslifueort, give street and
<br />St. Francis Memorial Health Center
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />Grand Island
<br />(Yrs) 74 Sb. MOS
<br />I
<br />8a. PLACE OF DEATH
<br />d ( , 711 (' i
<br />ER Outpatient
<br />DOA
<br />fid. INSIDE LIMIYnHall
<br />. COUNTY OF DEATH
<br />II
<br />Yes ;7,,,
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<br />ADDITION
<br />n TO THE CITY OF GRAND ISLAND, HALL COUNTY, NEBRASKA
<br />M
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMMT M- rA ALTH,
<br />IT CERTIFIES THE BELOW TO SEA TRUE COPY OF AN ORIGINAL RECORD ON F /LE if nor S` iTE _
<br />DEPARTMENT OF HEALTH, BUREAU OF V ?AL STATISTICS, WHICH IS THE LEGAL QEPflSMQ -Y FOi
<br />VITAL RECORDS.
<br />ATE Of ISSUANCE � -- -
<br />2 0 010 9 413 STAG r $. CQOm'
<br />FEB 3 1997 ASSISTANT ST44TAMG/$MA1f
<br />LINCOLN, NEBRASKA NEBRASKA DEPARTM &fOF Z*
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />DECEDENT - NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH tMomh. Day . Pearl
<br />Margaret C. Hansen Female January 25, 1997
<br />5a. AGE -Last Birthday UNDER t YEAR UNDER 1 DAV 6. DATE OF BIRTH /Monts. Day Yearl
<br />_. CITY AND STATE OF BIRTH Ill not n U S.A.. name country/ .._..__ � ... -...
<br />I Salt Lake City, Utah
<br />485 -12 -1466
<br />8b. FACILITY - Name lily not rnslifueort, give street and
<br />St. Francis Memorial Health Center
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />Grand Island
<br />(Yrs) 74 Sb. MOS
<br />I
<br />February 27, 1922
<br />OTHER 1:1 Nursing Home
<br />ElResidence
<br />❑ Other(Specdyl
<br />CD Co
<br />N E.
<br />CD �r
<br />CD
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<br />Y.
<br />CD
<br />C.0
<br />CD
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<br />CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Cade / 9e. INSIDE CITY LIMITS
<br />Nebraska Hall Grand Island 116 W. 17th St. , 68801 Yes ® No ❑
<br />10. RACE - e. White. Black. American Indian. 11. ANCESTRY (a g.. Italian. Mexican, German, etc) 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE Ill wile give maiden name/
<br />q((' 19.
<br />VVi►I�te) (peC�) r-1 NEVER DIVORCED Paul Hansen
<br />,merican
<br />74a. USUAL OCCUPATION /Give kind cf work date during most \ 14b KIND OF BUSINESS INDUSTRY
<br />of working life, even it retired]
<br />Home Maker Domestic
<br />T6. FATHER -NAME FIRST MIDDLE LAST 17 N
<br />Francis Charles
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? t9a. INFORMANT - NAI
<br />(Yes. no. or unk.) (if yes. give war and dates of services)
<br />No
<br />Paul Hansen
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />116 W. 17th St., Grand Island, Nebraska 68801
<br />20. EMBA SIGiN,AT RE LIC6M6 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME
<br />/L /,/ L_ Bpr;al Removal 01/28/1997 Westlawn Memorial Park Cemetery
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />22a. FUNERAL HOME -N E
<br />Apfel- Butler- Geddes Funeral Home ❑ Certalon ❑ Dooalion Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO, CITY OR TOWN. STATE, ZIP)
<br />1123 West Second Grand Island, Nebraska, 68801 -5899
<br />(ENTER ONLY ONE CAUSE PER LINE FOR lal. Ib). AND (cp Interval between onset and death
<br />23. IMMEDI/w US/E1
<br />PART
<br />I
<br />Ia1 I interval between onset and clean
<br />a DUET , OR S A CONSEQUENCE OF
<br />'
<br />(b) f, V`� ✓V i/V " ' Interval between onset and Beam
<br />DUE TO, R ACONS /E CONSEQUENCE OF I
<br />(cl OTHER SIGNIFICANT CONDITIONS - Caldkions contributing to the death bW - related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED 70 MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER�r
<br />II (Ages 10 -54) Yes No Yes No Yes No
<br />26a 26b. DATE OF INJURY (Mo.. Day Yr) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OC U RED
<br />Accident Undetermined LLqq M
<br />❑ Suicide Pending 26e. INJURY AT WORK 261 oNice buOildingaetoY /A, ho, ' farm. street. factory 26g. LOCATION STREET OR Fl.F.D. NO. Clio OR TOWN STATE
<br />Homicide Investigation Yes ❑ No
<br />O.. y W -1 28a. DATE SIGNED /MO.. Day. Yrl 28D TIME OF DEATH
<br />27a, DATE OF DEATH (M Da
<br />= Janua 25 1997 M
<br />27c TIME OF DEATH `y' g 26c. PRONOUNCED DEAD (Mo. Day, Yc/ 28tl. PRONOUNCED DEAD /Hour)
<br />VO 27b. DATE SIGNED (Mo.. Day. Yr) a < j
<br />1997 9:10 PM "��
<br />January f M M
<br />� g
<br />$ 27d. To the best of my nowl ge. death occurred tr time, dal nd Place and due to Me 28e. in
<br />causes) time, aa and place examination
<br />ats due/ o the aluselsl staled.�n�on death occurred al n he basis of
<br />causels) stated.
<br />(Signature and Tita S nature and T
<br />29. DID TOBACCO USE CONT (BUT TO THE DEATH? a HAS ORGAN OR TISSUE DONATION BE N CONSIDERED? ila 30.b WAS CONSENT GRANTED'
<br />YES O 11 UNKNOWN YES NO F1 YES NO
<br />31. NAME AND ADDRESS O C FIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print/
<br />Dr. John A. Wagoner Jr., 800 Alpha, Grand Island, Nebraska 68803
<br />R61 1I11f @Y REGISTRAR rMO. Day Yc/
<br />G retta
<br />15. EDUCATION (Specify only highest grade completed)
<br />Eternally or Secondary 10 -121 College 11 -4 or 5•I
<br />Coulam
<br />8a. PLACE OF DEATH
<br />HOSPITAL. a Inpatient
<br />ER Outpatient
<br />DOA
<br />fid. INSIDE LIMIYnHall
<br />. COUNTY OF DEATH
<br />Yes ;7,,,
<br />February 27, 1922
<br />OTHER 1:1 Nursing Home
<br />ElResidence
<br />❑ Other(Specdyl
<br />CD Co
<br />N E.
<br />CD �r
<br />CD
<br />I✓ �//w�
<br />Y.
<br />CD
<br />C.0
<br />CD
<br />C.J O
<br />CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Cade / 9e. INSIDE CITY LIMITS
<br />Nebraska Hall Grand Island 116 W. 17th St. , 68801 Yes ® No ❑
<br />10. RACE - e. White. Black. American Indian. 11. ANCESTRY (a g.. Italian. Mexican, German, etc) 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE Ill wile give maiden name/
<br />q((' 19.
<br />VVi►I�te) (peC�) r-1 NEVER DIVORCED Paul Hansen
<br />,merican
<br />74a. USUAL OCCUPATION /Give kind cf work date during most \ 14b KIND OF BUSINESS INDUSTRY
<br />of working life, even it retired]
<br />Home Maker Domestic
<br />T6. FATHER -NAME FIRST MIDDLE LAST 17 N
<br />Francis Charles
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? t9a. INFORMANT - NAI
<br />(Yes. no. or unk.) (if yes. give war and dates of services)
<br />No
<br />Paul Hansen
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />116 W. 17th St., Grand Island, Nebraska 68801
<br />20. EMBA SIGiN,AT RE LIC6M6 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME
<br />/L /,/ L_ Bpr;al Removal 01/28/1997 Westlawn Memorial Park Cemetery
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />22a. FUNERAL HOME -N E
<br />Apfel- Butler- Geddes Funeral Home ❑ Certalon ❑ Dooalion Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO, CITY OR TOWN. STATE, ZIP)
<br />1123 West Second Grand Island, Nebraska, 68801 -5899
<br />(ENTER ONLY ONE CAUSE PER LINE FOR lal. Ib). AND (cp Interval between onset and death
<br />23. IMMEDI/w US/E1
<br />PART
<br />I
<br />Ia1 I interval between onset and clean
<br />a DUET , OR S A CONSEQUENCE OF
<br />'
<br />(b) f, V`� ✓V i/V " ' Interval between onset and Beam
<br />DUE TO, R ACONS /E CONSEQUENCE OF I
<br />(cl OTHER SIGNIFICANT CONDITIONS - Caldkions contributing to the death bW - related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED 70 MEDICAL
<br />PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER�r
<br />II (Ages 10 -54) Yes No Yes No Yes No
<br />26a 26b. DATE OF INJURY (Mo.. Day Yr) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OC U RED
<br />Accident Undetermined LLqq M
<br />❑ Suicide Pending 26e. INJURY AT WORK 261 oNice buOildingaetoY /A, ho, ' farm. street. factory 26g. LOCATION STREET OR Fl.F.D. NO. Clio OR TOWN STATE
<br />Homicide Investigation Yes ❑ No
<br />O.. y W -1 28a. DATE SIGNED /MO.. Day. Yrl 28D TIME OF DEATH
<br />27a, DATE OF DEATH (M Da
<br />= Janua 25 1997 M
<br />27c TIME OF DEATH `y' g 26c. PRONOUNCED DEAD (Mo. Day, Yc/ 28tl. PRONOUNCED DEAD /Hour)
<br />VO 27b. DATE SIGNED (Mo.. Day. Yr) a < j
<br />1997 9:10 PM "��
<br />January f M M
<br />� g
<br />$ 27d. To the best of my nowl ge. death occurred tr time, dal nd Place and due to Me 28e. in
<br />causes) time, aa and place examination
<br />ats due/ o the aluselsl staled.�n�on death occurred al n he basis of
<br />causels) stated.
<br />(Signature and Tita S nature and T
<br />29. DID TOBACCO USE CONT (BUT TO THE DEATH? a HAS ORGAN OR TISSUE DONATION BE N CONSIDERED? ila 30.b WAS CONSENT GRANTED'
<br />YES O 11 UNKNOWN YES NO F1 YES NO
<br />31. NAME AND ADDRESS O C FIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print/
<br />Dr. John A. Wagoner Jr., 800 Alpha, Grand Island, Nebraska 68803
<br />R61 1I11f @Y REGISTRAR rMO. Day Yc/
<br />G retta
<br />15. EDUCATION (Specify only highest grade completed)
<br />Eternally or Secondary 10 -121 College 11 -4 or 5•I
<br />Coulam
<br />
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