|
11�II�IIIIIII�,Illiis),.0 tte11��1�/;f��
<br />,,,y��1111iff/(I%%iy%tri rNe���Ni)�iil((l
<br />trrfh1j'fAi, yo111j1(
<br />,� s�ti697111(1uJJ��a � c
<br />WHEN THIS 'COPY.' CARRIES . THE RAISED SEAL OF THE STATE OF NEBRASKA IT
<br />CERTI IES ,THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINALRECORD
<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 OflISSUANCE
<br />9/3/202x7
<br />LINCOLN, NEBRASKA
<br />62093'
<br />.
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1, DECEi7ENr$ M{1ME ('#hist, Middle, Last, Suffix)
<br />Bonnl LOO " Hansen
<br />TY:AND STATE ORTERRITORY,!
<br />Grand Island, Nebraska
<br />T, SOCIAL SECURfTY NUMBER
<br />€x5=42 3718:
<br />FOREIGN COUNTRY OF BIRTH
<br />5a. AGE Last Birthday
<br />(Yrs )
<br />B
<br />8
<br />8b. FACILITY -NAME Of net Institution, give street and number)
<br />Wedgewood Care Center
<br />8c CITY OR TOWN OF OEATH (include Zip Code)
<br />Grand Island 68803'
<br />ga. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />(lb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ba. PLACE OF DEATH
<br />HOSPITAL ❑ inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />2011473
<br />3. DATE OF DEATH (AAo ,- Day, Yt)
<br />August 28, :2020
<br />6. DATE OF BIRTN (Mo., Day,
<br />April 14, 193.5
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND NUMBER :.
<br />212 West Bartett Avenue
<br />1f)a MARITAL STATUS AT TIME OF DEATH ® Married ❑Never Married
<br />Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FAIRER 8 NAME (First, Middle, Last'
<br />ast Suffix)
<br />Gei rge Edward Sass
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) NO
<br />16. METHOD OF DITION
<br />I Buttal O SPOSIDonation
<br />❑ Cremation 0 Entombment
<br />©Removal :❑ Erttlet (Specify)'
<br />Se. APT. NO.
<br />1011. NAME OF SPOUSE (First, Middle,
<br />Harold Louis Hanssen
<br />12. MOTHER'S NAME (First, Middle,
<br />Caroline Margaret Dibbern
<br />Sf. ZIP CODE
<br />68832
<br />9g INSIDE CITY t:Hfll(TS
<br />Yes ;; ❑ No
<br />Last, ; Suffix) if wife, give maiden n(
<br />14a..INFORMANT-NAME
<br />Harold Louis Hanssen
<br />18a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION'
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />A:Falths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />m
<br />16b. LICENSE NO.
<br />1071
<br />CITY / TOWN
<br />Grand Island
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DE'.
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />September 4 2020
<br />CAUSE OF DEATH (See instructions and'examoles)
<br />8. PART I. Enter the chain or events. diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE;(Final a) Stroke
<br />disease orcondifton�resulting
<br />in deatttl
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, ti b)
<br />any, leading to the wase gated
<br />di latae d DUE TO, OR ASA CONSEQUENCE OF:
<br />E Erni the UNDEfiLYING
<br />(disease ortnjuryI"GII0 itiatsd
<br />ate evetna resultd)
<br />restating In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />'3
<br />Nebraska
<br />in. Zip Code
<br />88801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Weeks
<br />onaat'to;
<br />onset ..
<br />onsetto death
<br />18. PART IL OTHI R SIQNIFCANT CONDITIONS -Conditions contributing to the death but not
<br />Otl Utl Wtt ribephalopathy, Cerebral Palsy, Paroxysmal Atrial Fibrillation
<br />20. IF FEMALE:
<br />❑ N'otpragtrentwgam••ast••eer
<br />❑ P sgnantattinieoldeetit
<br />❑ NFtIragnard, #itat pregtiantwithin 42 days of death
<br />❑ Not pregnant, but pregnant 43 days tot:year before death
<br />❑• Unknown it pregnant within the past year`
<br />22a DATE OF INJURY.(Mo.,;Day, Yr.)
<br />22d. INJURY AT WORK/
<br />YES 0 N
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />resulting In the underlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />DnvertOperator
<br />•
<br />Passenger
<br />EThilledestrlan
<br />0 Other (Specify)
<br />19. WAS MEDICAL EXAMINER ,><
<br />OR CORONER CONTACTED'?
<br />❑ YES ®NO,
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®;NO
<br />21d. WERE AUTOPSY FINDINGS AVAIABLE
<br />TO COMPLETE CAUSE OFDEATH?
<br />❑ YES ❑ .No
<br />22c. PLACE OF INJURY -At homs, farm, street, factory, office building, construction site, etcfSpeelfy)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE, OF DEATH (Mo„ Day, Yr.)
<br />August 28, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />August 28. 2020
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />02:30 AM
<br />3d TOMO beef Of my knowledge, death occurred at the time, date and place
<br />and dtie t4 the 4aise(a) stated. (Signature and Title)
<br />Richard Fruehlinq, MD
<br />STATE
<br />24a.. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />248: On the basis of examination and/or InvestIgati4 In my opiniondeajh Ottuffe
<br />ad 8t
<br />the time, date and place and: due to the ceuse(s) sated. (signature add XIII*)
<br />26a. HAS ORGAN OR TISSUE DONATIONBEEN CONSIDERED?
<br />❑ YES El NO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑`YES NO I� PROBABLY 0 UNKNOWN
<br />47 N {(ME,'i)YLE 1,11 ADo ESS Op CERTIFIER (Type or Print
<br />Rtchard Fn. ehli•ng, MD, 2116; W Faidley #400, Box 9802, Grand Island, Nebrask,
<br />28a. REGISTRAR'S SIGNATURE
<br />0-2 4.-11 rx
<br />26b. WAS CONSENT GRAN
<br />Not Applicable N 2tSa Ie NO
<br />8803
<br />28b. DATE FILED BY REGISTI
<br />August 31, 2020
<br />0)
<br />o`
<br />
|