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STATE OF NEBRASKA
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<br />I
<br />HEN THIS COPY CARRIES THE RAISED SEAL OF STATE QF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA :;DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF Is$UAAICE
<br />7/29/2024
<br />LINCOLN, NEBRASKA
<br />202404245.;
<br />ARA08.441,41
<br />BOHNENKAII P
<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 />mseeas f. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Lair t James Hansen
<br />4 CITY.AND .S1ATS OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />LOnp Pine, Nebraska
<br />7!,:�SOCtALSecuat. YNUMBER
<br />506.84»3983
<br />5 sit. FACILITY -NAME (If not Institution, give street and number)
<br />Veterans Affairs Medical Center
<br />8C. CITY OR Tt'9WM OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a; RESIDENCE -STATE.
<br />Nebraska
<br />9djSTREETAND NUMBER
<br />908 S Vine Street
<br />9b. COUNTY
<br />Hall
<br />.5a, AGE • LastBirthdsy
<br />(Yrs.)
<br />82
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ba. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />V 10a MARITAL.STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />a
<br />❑ Married, but separated lAi Widowed 0 Divorced 0 Unknown
<br />11.FATHER&NAME (First, Middle, Last, Suffix)
<br />McMn Hansen;:
<br />12. EVER IN G.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 08/21/1959-08/24/1962
<br />v
<br />16. ME t -»t
<br />4.J Donation
<br />Cremation Entombment
<br />TNOD OF DISPOSITION
<br />❑
<br />c Remotral Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF?DEATH fN1.o,,,Da% Yr)
<br />July
<br />24,1024.'
<br />6, DATE OF BIRTH
<br />August:27, 1941
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH'
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give mai
<br />Karen Christensen
<br />l12. MOTHER'S -NAME (First, Middle, Maiden Summitl
<br />Myrtle Lawyer
<br />>lg )
<br />SIDE CITY:LIMITS
<br />Yes Q NO
<br />n name
<br />14a. INFORMANT -NAME
<br />Brian Hansen
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />1Ta FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ivinllstotl-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska;
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. 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 Nbruta,ion without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />a)Malignant melanoma
<br />14b. RELATIONSHIP TO. DECEDENT
<br />Son
<br />16c. DATE(Mo Day,Yr)
<br />July 26, 2Q24
<br />Indeatt)
<br />Sequentially list conditions, If
<br />a!ty, leading tothe ceas*1,ted
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Metastatic disease to spine, liver, lungs and brain
<br />UNDERLYING CAUSE.
<br />(disease or kijitry that Undated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />STATE
<br />Nebraska
<br />9Tb.Zip'Code ..
<br />•
<br />68808 '
<br />APPROXIMATE INTERVAL
<br />... to death
<br />Four Years!
<br />S 18. PART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not re
<br />Adenocarcinoma of prostate
<br />es
<br />• 20, .TF FEMALE;
<br />Not pregnant within pant year
<br />0 Pregnant at time of deatp
<br />D Not pregnant, but pregnant within 42 days of death
<br />V0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown Npregnant within the peat year
<br />22a. DATE OFINJURYMo., Day, Yr.)
<br />E 22d. INJURY AT WORK?
<br />❑ YES .::❑NO
<br />: 22f. L(
<br />w
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />lilting In<
<br />22b. TIME OF INJURY
<br />underlying cause given in PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />© Ddver)Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />19. WAS MEDICAL EXAMINER:
<br />OR CORONER CONTACTED?
<br />DYES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED
<br />Q YES 1 Nff
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES D NO
<br />22c. PLACE OP INJURY -At flOrl , farm, street, factory, office building, construe
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />TION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 24 2024
<br />230 DATE SIGNED (Mo., Day, Yr.)
<br />Jute 24 2024
<br />n miter:
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />12:33 AM
<br />230 To the bast oflny knowledge, death occurred at the time, date and place
<br />a!id &widths cause(*) stated. (Signature and Title)
<br />Jennifer Kinq, MD
<br />ToeAGCO USE CONTRI$UTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />t l YEs NO °❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24h. TIME OF DEATH
<br />24d.111
<br />PRONOUNCED DEAD.
<br />24e On the:basis of examination and/or Investigation, M my Opinion de tit occuiyad^
<br />the:tme, date and place and due to the cauaefe) Orated. t8I9narurs a,w Ttte)
<br />0 YE$ ® NO
<br />7 NAME TY1`IE ANbAODRESS OF CERTIFIER (Type or Print
<br />Jennifer King, MD, 2201 N Broadwell Ave, Grand Island, Nebraska, 68803
<br />288. REGISTRAR'S SIGNATURI
<br />.6.411-e?
<br />26b. WAS CONSENT GR 4TTEDT :
<br />Not Applicable if 28s Is NO ❑ YES
<br />28b. DATE FILED BY REG
<br />July 26, 2024
<br />y,Yr.)
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