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<br />STATE OF NEBRASKA
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<br />froVNEN T3JI8 coFY GARR:WS-THE RAISED SEAL OF LANCASTER Cf t;FNTY NEBRASKAIT CERTIFIES THE
<br />DCIGUJ6lENTBeitoW t4) kig-A TAUE COPY 014 Pis ORIGINAL RECORD ON FILE KIM THELANCASTERCOUNTY
<br />HEALTH DEPARTMENT VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />202208651:
<br />LINCOLN, NEBRASKA
<br />'... �1 !l11n "�•
<br />11►v1i41vi,XV ",(CW., 1, Ibo;1‘u1♦,riillir IUIYr 11))))
<br />711rnnii,(U(„I r.irggl��YY��u ,,,�` tryi�YA"))ir
<br />161d1p1,lyl,n„_ ?�914L'1111111iP�a �- rents
<br />x44,.,./7T il/E JLeiYl sera: p
<br />SARAH BOHNENKAMV.
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN.SERV[CES'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE %tND SUPPOF{ rj �j �j
<br />, CERTIFICATE OF DEATH u G 2 j, `}
<br />(Pine, Middle, Last, Bunts)
<br />Gerald Eugene Hensley
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Central City, Nebraska
<br />7>t30C1AL8ECURITY MUMB>*'R
<br />506-284;45
<br />T591
<br />tib, FACILITY NAME, (11 not Inatitutlon,,giw street and number)
<br />Tiffany Square Care Center
<br />•CITYOR'f0WNOFDEATHnotud.ZIP
<br />Cede)
<br />Grand island 68803
<br />Oa.RESIDENCE$TATE
<br />Nebras
<br />Ob. COUNTY
<br />Hall
<br />5a. AGE -Last Birt•hday
<br />(Yrs) 79
<br />Sb. UNDER 1 YEAR
<br />2. S6X
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />8. DATE OF DEATH (Mo., Day, Yr.)
<br />October 9, 2009E
<br />6. DATE OF. BIRTH (Mo., Day, Yr.)
<br />March 24, 1930
<br />SeP1;ACE OF DEATH
<br />HORPITAJ,
<br />ild.COUNTY OF DEATH
<br />Hall
<br />.10a.CITY ORTONM
<br />Woad River.
<br />X04 .:East 13th_
<br />lea. MARITAL STATUS ATTIME OF DEATH !iMam"Q ( Never Married
<br />QMarded,bid deq eted IWldayed ODWot..d'OWdmown
<br />8a. AP7. m0
<br />1 FATtLER'8;t1AME...(Fk,, Middle,
<br />Joseph E.
<br />18. EVER L. U.B. ARMED FORCES? Give dales of service II yse.
<br />(vseikPank) 2/1../1951 1/25/1955
<br />1d ME1?t0DOFDISPOSITION 18a.EM R -SIG
<br />„Olt IOcnetloi+
<br />abrisi*dori O i nlombmenl
<br />Removal O Omer (Bpi,4fA
<br />11 FUP)EHALHOMENA1+MEANDMAIUNOADDRE99 (Brsel,Cly orTown, State)
<br />1Apfel21,00.0al Home, 1123 West Second, Grand Island,
<br />N. ZIP CODE
<br />68883
<br />106. NAME OF SPOUSE (Fina, Mtddle, Leat, Suffix) it wile give maiden name.
<br />Marian Mae Craft
<br />Lest, Suffix)
<br />Hensley
<br />Op. 114eXtE WY WITS
<br />YES O NO
<br />12. MOTHE{('8-NAME '(First,
<br />i'esse
<br />44.. INFORMANYNAME
<br />Marian .Bensley
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island Cemetery
<br />Meddle,
<br />C.
<br />124b LICENSE NO.
<br />/2 Via
<br />Malden Surname)
<br />Breckon
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16o. DATE (Mo., Day, Yr. )
<br />October 14, 2009
<br />CITY/TOWN
<br />STATE
<br />Grand Island, Nebraska
<br />0. PART)
<br />raegka
<br />ebraska
<br />176. Zip Code
<br />68801
<br />Enter Me ,1n)udee, or aompNostlons..that directly caused the depth. DO NOT enter terminal ev6nl5 such ea cerdiso erne,
<br />y efresl,9r wa l6Mar IWri8elion "Mold showing the etiology. 00 NOT ABBREVIATE. Warmly sae muse on a goo Add additional:eoee II n.c aaary.
<br />EIMEOIATECAUSE:
<br />vt-
<br />BlMeallreclume(fatlr la) M��� S\,Q.11C/�-L
<br />dideawarePedl lonraal0tlg DUE TO OR AS A CONSEQUENCE
<br />rBo!>,8. oj),Vo911eiJ),.C<t%('.YQ, clilN•li, ce7�wl�rlutiI"iY!D}[
<br />erg,teddingteSlaanata8+t d. ,DUE TO, OR AS A CONSEQUENCE OF: '
<br />(dlesalearthey SMwort (tri e\ep*?j1r %AL.& OS,, eKriirS
<br />IndeltM :> 111Ia
<br />19eerthsUtJDERLYENGCA SE
<br />TO, ORAS A CONSEQUENCE OF:
<br />PROKI
<br />Murat todeath
<br />WMUv1%
<br />onset to death
<br />yt
<br />angel M dead%'
<br />to
<br />18. PART t(:9THER 8KNI1 CANT CONDITIONS -Conditions aontribu0ng to the death but not reeUllin In the undarying cause given in PART 1.
<br />8#iN<Ftt3(dAL1I:' ::
<br />Cf NbtpregMatwOMnpeslgeu
<br />Preened, Ointrof death
<br />Ll: Nolpregnerdl MA prilmapt wtihtn 42 days of daelh
<br />( Notpregneht4atptagaanL4Bdayeto1yearbetoredeath.,
<br />UnkaPim ly i4SnantHRlMa he P..t year
<br />21e. MANNER OF DEATH
<br />.Nelural O Homldde
<br />O'AccidentO Pending myealgalion
<br />OSulalde 0Could nmbedetonated
<br />PHM )F TRAN8PO4TAT1ON INJURY
<br />❑DEvar/Opamter
<br />❑ Passenger
<br />O Pedestrian
<br />❑ biker (Sp eifit
<br />( 1e. WAS MEDICAL WANNER
<br />IOR`ER VIIPLIEDT
<br />O YES lilf NO' -
<br />2/c.WAS ANAUTOPSY PERFORMED?
<br />CI YE8 NO •
<br />21d. WERE AUTOPSY FINDINGSAVA6ABLETO
<br />COMWLETECAUSEOFDEATH?
<br />O YE8 O 140
<br />22s. DATE OF INJURY (TI
<br />Day, Yr.) 228. ME OF INJURY 122s. PLACE OF INJURY -Al home lean, street, factory, office building, aonstru0Uon silo, eta (Specify)
<br />m
<br />ATWCRK7 220. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY • STREET 8 NUMBER, APT. NO.
<br />CITY/TOWN
<br />ZIP CODE
<br />23.. DATE OF0EATH (Mo., Dey, Yr.)
<br />SNN40„(Ma, Day, Y,,)t Mo. TIME OF DEATH
<br />\a --13-u'1' fad m
<br />840.1DATE SIB/IEO 4Mo„;Day, Yr.)
<br />24b.TIME OF DEATH
<br />m
<br />2:34, To the beet.,gLml(.
<br />and
<br />at the time, date and place
<br />rid Thie)V
<br />OBEs 1(11RIBUTETOTHEDEATH?
<br />O
<br />YES 0 NO PROBABLY 0 UNKNOWN
<br />27.NAME,TITLE AND ADON SSOFCERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR CPUNTYATTORNEY)(1YPeorPdMB
<br />Steve Huen MD. 2116 W. Faidley dive,. , Grand Zaland, 68803
<br />RONgUNCEti DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED
<br />m
<br />24s. On the bash el examination and/or investigation, In tryton death opourred
<br />the Oma, date and place and due to the onsets) alaNd. (Signature and Title ) V
<br />26a HAS ORGAN OR TISSUHDONATl0NOEEN CONSIDERED?'
<br />0 YES 'N0
<br />266. WAS CONSENT GRANTEDT
<br />Not Applicable II 26a Is NO 0 YES
<br />2tbREGISTR/ifIGS1GNATURE
<br />1 25b. DATE FILED BY REGISTRAR (Ma; 0112,Y11
<br />OCT. 212
<br />
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