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<br />STATE OF NEBRASKA
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<br />: -WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT'CER'TIFIES THE DOCUMENT BELOW TO:
<br />EEA TRUE COPY' OF TFIE ORIGINAL RECORD ON FILE WITH THE NEERASNk DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OP ISSUANCE
<br />7/21/2023
<br />LINCOLN, NEBRASKA
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<br />2 0'2 3 0'4 6 2 4`SARAH BOHNEN>< AMP
<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 />t DECEDENTS -NAME {First, Middle, Last, Suffix)
<br />Stephan(® Lynn Hansen
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />SOCIAL: SECURITY:NUmaER
<br />508-600317
<br />b. FACILITY -NAME (Ir not Institution, give street and number)
<br />2135 Brahma Street
<br />is
<br />8c. CITY OR TOWN OF.DEATH (Include Zip Code)
<br />Gcand Isiatd 68811
<br />t 'RESIDENCE STATE
<br />Nebraska
<br />ltd. STREET AND NUMBER:;.
<br />2135 Brahma LStreet
<br />1.Oa, MARITAL STAT AT TIME OF'DEATH ® Married 0 Never Married
<br />Married, but separated ❑Widowed
<br />0 Divorced ❑ Unknown
<br />9b. COUNTY
<br />Hall
<br />St AGE - Last Birthday..:
<br />(Yrs.)
<br />71,.;.
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />0 DOA
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Claanj, Nore
<br />. EVER IN U.S, ARMED:FORCES'
<br />(Yes, No, or Unit:) No
<br />15. METHOD OF DISPOSITION
<br />®; Suite) ❑Donation
<br />❑;Cremation:] Entombment
<br />❑<Removal ❑Other(Spedfy).'
<br />Give dates of service if Yes.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (MO., Day, Yr,)::,
<br />23 09405
<br />July 10,2023:V.::.:
<br />8. DATE OF BIRTH (Mo., Dep, Yr.)`
<br />March
<br />OTHER 0 Nursing Home/LTC
<br />E Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />lie. APT. NO.
<br />St. ZIP CODE
<br />68801
<br />Os INSIDE CITY UNITS .
<br />05 'res ❑
<br />106, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife 'give maiden na
<br />John Charles Hansen
<br />12. MOTHER'S•NAME (First, Middle, Maiden Surname)
<br />Cleo Jeannine Edwards
<br />14a. INFORMANT -NAME
<br />John Charles Hansen
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION.
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Fai hs Funerat Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATEF(See instructions and examples)
<br />I. PART I. Enter the chain of 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 />a) metastatic lung cancer
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Grand Island
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo.,,Day„Yr.)
<br />July 15,;2023
<br />SAMEDIATE DAUBE IFinai
<br />disea#e or condition seauaing
<br />in death)
<br />•
<br />to Sequentially list conditions, If
<br />any, leading to the cause listed
<br />on lima
<br />Enterthe UNDERf VINO CAUSE]:
<br />(dlseaes winjury.hat lnitlatee
<br />D;stilo,events resulting in death)
<br />LAST
<br />18..PART II.OTHER SIGNti
<br />DUE TO, OR A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR A CONSEQUENCE OF:
<br />d)
<br />ANT CONDITIONS -Conditions contributing to the death b
<br />a
<br />rri
<br />O. IF FEMALE:
<br />Not pregnant within past year
<br />[i Pregnetd at OTne of death,
<br />` Mot pregnanta£but pregnant within 42 days of death
<br />Not pregnant, but pregnant 43 days to 1 -:year before death
<br />:.❑ Unknown if pregnant wkhin the past year
<br />22a. PATE OF INJURY (Mo, Day, Yr.)
<br />224. INJURY AT WORK?
<br />❑YES 0 N
<br />21a. MANNER OF
<br />❑ HomicideDEATH
<br />❑ Accident
<br />Natural ❑ Fending
<br />Investigation
<br />0 suicide ❑Could not be determined
<br />e underlying cause given in PART I.
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ UrivaHOperator
<br />Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />TATE
<br />Nebraska
<br />17b, Zip Code
<br />• 58801
<br />APPROXIMATE INTERVAL
<br />onset ttideatEt .
<br />40 Months
<br />onset to death
<br />onset
<br />onset to death
<br />19. WAS MEDICAL EXAMER
<br />OR CORONER CONTACTED?
<br />❑ YES; ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®MO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑' YES ❑ NO :.
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc (Sptcfiy)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />. LOCATION INJURY:' STREET ii NUMBER, AP T.NO.
<br />2
<br />23a. DATE OP DEATH (Mo., Day, Yr.)
<br />July 10, 2023
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />04:06 PM
<br />July 14 2023
<br />To ata best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />Ryan Ramaekers, MD'
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />het YES Ill NO l,,f'PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Ryan Raniaekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH'`
<br />24d. TIME PRONOUNCED DEAD
<br />24e. on the bssle of examination and/or Investigation, in my opinion least occurred at
<br />the fl nla„date and place and due to the cause(s) stated. (Signature, and TMs)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES RI NO ..
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable ff 26a Is NO 1.,3 YES CI NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 17, 2023
<br />
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