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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />C RTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL, RECORD
<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 />GATE
<br />OF ISSUANCE=
<br />9/3/2020
<br />LINCOLN, NEBRASKA'
<br />202206611
<br />ICA it R hr
<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 />DE rk" EDENTS-NAMI£ (First,
<br />,E+nnie Lou Hanssen
<br />Middle, Last,; Suffix)
<br />4. CitY.. BC STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOC(ALSECURITY NUMBER
<br />505=42:371.6
<br />8b. FACIL4TY-NAME (If l of Irtatituuon, give street and number)
<br />Wedgewood Care Center
<br />Sc. CITY OR TOWN QF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />6a. RE'S(DENCE=STATE
<br />Nebraska
<br />'Sri. STREET AND NUMBER.
<br />212 West Berta Avenue
<br />9b. COUNTY
<br />Hall
<br />5a AGE - Last Birthday
<br />(Yrs.)
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Ou patient
<br />0 DOA
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER S NAME (Pits!.: Middle,
<br />George Edward Sass
<br />Suffix),
<br />Sc. CITY OR TOWN
<br />Doniphan
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo. Day;
<br />August 28;2020'
<br />6. DATE OF BIRTI}(iplo., Day, Yr)
<br />April 14, 1935
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />8f. ZIP CODE
<br />68832
<br />10b. NAME OF SPOUSE (First, ' Middle, Last, Suffix) If
<br />Harold Louis Hanssen
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />4s. METHOD OF DISPOSITION
<br />Sttrtel ] Donation
<br />•••,••••,•
<br />Entomb ant
<br />emovai Q Other (Specify)
<br />§g.INS D. CI7 YLti H S .
<br />1 Y'E8 ❑ M0
<br />ife, give maiden name
<br />12. MOTHER'S -NAME: (First, Middle, Maiden Surname)!
<br />Caroline Margaret Dibbern
<br />14a. INFORMANT -NAME
<br />Harold Louis Hanssen
<br />16a. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />18d. CEMETERY, CREMATORY OR OTHERS LOCATION
<br />Grand Island City Cemetery
<br />1Ta. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State);,,
<br />All Faiths Funeral flame, 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1071
<br />CITY I TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />1e. PART 1. Enter the chain of events' Elseysea; Injuries, or compiicationsthat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />retaliatory arrest, or far fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />al Stroke
<br />1MME1fA'iS CAUSE (Finer
<br />dieShi a or CCnditien reauiftng
<br />In death):::,,
<br />Sequentially list conditions, it
<br />any, leading to the cause Bated
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo. Day, Yr.)
<br />September4.2020
<br />STATE
<br />Nebraska
<br />1Tt1,_ Zlp::Code
<br />:688(t1
<br />APPROXI
<br />onset to death:.::
<br />Weeks
<br />YE INTE
<br />delete
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />.EnfeititetmNDERPON9OAUSE
<br />(drseaae.. ireury:that initiated
<br />the events resulting In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to death
<br />18. PART li OTHER S(GN(FICANT CONDITIONS -Conditions contributing to the death but not resulting In
<br />• E. CoIiUc With iEnCeptlalopathy, Cerebral Patsy, Paroxysmal Atrial Fibrillation
<br />20 IF FEMALE:
<br />Not pregnant within past year:
<br />❑ Piegrantatamaordaath
<br />❑ t4ot yzr agnara q of pregitsm within az days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown H pregnant within the past year
<br />225.11ATE OF IN:titURY (Mo, Pay,Yr.)
<br />22d. INJURY AT WORK?)
<br />YES ❑ NO
<br />22f J O:CATION:
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending'nveaflgat
<br />❑ suicide 0 Cduld not be determined
<br />22b. TIME OF INJURY
<br />DESCRIBE HO
<br />e underlying cause given In PART I.
<br />21b. IF TRANSPORTATION
<br />❑ Dnverlopetator
<br />❑:Passenger'
<br />0 Pedestrian
<br />0 Other (Specify)
<br />INJURY
<br />1e. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED',
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?.
<br />❑ YES IE NO
<br />21 d WERE AUTOPSY Fj)"NDINGS Ali'a't€(.,ABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑-NO
<br />22c. PLACE OF INJURY -At home, farm, Street, factory, office building, construction site, etc; ISpec..)
<br />NJURY OCCURRED
<br />URY.. STREET & NUMBER, APT.NO.
<br />23a, DATE OF DEATH (Mo., Day, Yr.)
<br />August 28, 2020
<br />3b. DATE SIGNED Day, Yr.)
<br />August 28, 2020
<br />CITYITOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />02:30 AM
<br />ad. To the'.beft Of my knowledge, death occurred at the time, date and place
<br />and clue to the Gamete) stated, (Signature and nue)
<br />Richard Fruehling, MD
<br />24c. PRONOUNCED D
<br />D (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME UNCED DEAD
<br />4e. On the Iasis of examination and/or Investigation, in my opinion deet!) oetxnrr'ed et
<br />theiime, date and place and due to the cause(s) stated. (Signature and Title)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES Er NO
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />t0NO ❑;PROBABLY 0 UNKNOWN
<br />27. NAME,'fTLSltNO ADDRESS OF CERTIFIER (Type or Print
<br />Ritard Freehling, MD, 2116 W Faidley #400, Box 9802, Grand Is = +raska 68803
<br />❑ YES
<br />28a. REGISTRAR'S SIGNATURE
<br />2 .8a n, C.zrrr. -
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ' ;❑ YI s
<br />CD
<br />NO,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 31, 2020
<br />
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