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9a RESIDENCE STATE 9b COUNTY
<br />—' 1111 WlAl1L
<br />19c CITY TOWN OR LOCATION 9tl STUMBE Zp Codel 9e INSDE CITY LIMITS
<br />Nebraska Hall Count Grand Island 31 Faidley, 68803 Yes x❑ NO ❑
<br />10 RACE leg.. While Black Amencan Indian TIT ANCESTRY
<br />rS0ecilyl
<br />C-) cn
<br />etc I ISpecrtyl
<br />White
<br />I�If
<br />°p
<br />IGb KINDOFBUSINESSI N DUSTRY 15 EDUCATION I Speclly only highest grade compleledl
<br />-n
<br />C
<br />1= m cn
<br />rn
<br />N
<br />:16FA:T�HER
<br />Henry H,
<br />Hansen Dorothy UNK Plambeck
<br />i6 WAS DECEASED EVER IN US ARMED FORCES'
<br />--
<br />.a INFORMANT NAME -
<br />-�
<br />O CAD
<br />No N/A
<br />Lorraine Hansen
<br />Q
<br />= N
<br />o
<br />o
<br />20 EMBA IM�R- SIGNATURE B LICENSE NO
<br />)
<br />21a ME THOD OF DISPOSITION 21b DATE i 21c CEMETERY OR CREMATORY NAMEn�Iete
<br />`
<br />�' -- /" -
<br />I
<br />Z
<br />1 210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Kleine Funeral Home
<br />❑ = -hon ❑ oonalo, j
<br />Ashton Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.
<br />m
<br />= M
<br />y
<br />28b TIME OF DEATH
<br />EXAMINE OR CORONER'
<br />$
<br />o�
<br />m \�
<br />r z�
<br />27E TIME OF DEATH
<br />(Ages 10 54 Yes Na
<br />Yes No
<br />�
<br />Yes 7 No I
<br />r D
<br />N CO
<br />OO
<br />20d. PRONOUNCED DEAD (He,,,
<br />N
<br />vX
<br />co "mot
<br />i- z..�` -Io
<br />o N -o
<br />C
<br />To the best of my knowledge
<br />death occurred at
<br />the time
<br />M
<br />co
<br />I'27d date and olace due to the
<br />cause(sl staled. /
<br />tL�.MV'�'v- IV,
<br />CC/) /)
<br />° ¢� j f
<br />-
<br />268 On the basis of examination and or —v hg.uon, in my opinion death occurred at
<br />mr, lime. date and place and 0ue 10 the cduselsl slated.
<br />�: w
<br />Signature and Title(► • -� t
<br />® ISM Title)
<br />29 DO TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30 :a HA DRGAPI OR TISSUE
<br />DONATION
<br />nature and ►
<br />—
<br />SEEN CONSIDERED' 30A WAS CONSENT GRANTED'
<br />0 �l `
<br />❑ YES ❑ NO UNKNOWN
<br />YES YES
<br />N�) I VES nIC
<br />U
<br />WHEN THIS COPY CARRIES THE RAJSED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />William J Landis MD 2444 W. Faidle
<br />Ave. Grand Island Nebraska 68803
<br />Q
<br />32a REGISTRAR
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />a)
<br />— - - - -- — - 9'J'' a''�
<br />r � AUG 2 0 2001
<br />oa 0
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />200112865 StANLEY
<br />S COOPER
<br />AUG 2 2 2001
<br />ASSISTANT STA TE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPFrORT
<br />VITAL STATISTICS
<br />CERTIFICATE 0 1
<br />( 2
<br />1� 9 �. ? %
<br />-
<br />_ OF DEATH
<br />I DEI;EDE NT
<br />�
<br />-NAME FIRST MIDDLE LAST Z SEX 3 DATE OF DEATH ;Mrrrm (Tar bear;
<br />Q
<br />La ern Howard Hansen Male Au
<br />st 11 2001
<br />W
<br />Q
<br />d
<br />CITY AND STATE OF BIRTH Illnnf m USA name,0111111; AGE - Last Birthday UNDER 1 YEAR UNDER I DAV 6 DATE OF BIHiH ;Month Dar
<br />__-
<br />z,x
<br />l5a
<br />)Yrs: MOS DAYS 5c HOURS MINS
<br />�5b
<br />Rockville Nebraska 80 July 1, 1921
<br />7 SOC14L
<br />O
<br />SECURTIY NUMBER 11, PLACE OF DEATH
<br />--
<br />Y
<br />- 520 -16 -1918 HOSPITAL ❑ mpahenl OTHER N1r„ RHrrmn
<br />Z�
<br />Q
<br />6b Fr1C4rtV -Name Ill nonnsblu(ron. grve Sbeei and numbed El Outpatient El Residence
<br />DOA
<br />❑ °OA ❑ Other ,per-d, TifnASdare Care Center
<br />}
<br />f
<br />it
<br />Bc ('IT\ TOy G DEATH ', Hd INSIDE CITY LIMITS Se COUNTY OF DEATH
<br />- -- �
<br />Grand T- l FY-1 n
<br />an,� ) f7
<br />9a RESIDENCE STATE 9b COUNTY
<br />—' 1111 WlAl1L
<br />19c CITY TOWN OR LOCATION 9tl STUMBE Zp Codel 9e INSDE CITY LIMITS
<br />Nebraska Hall Count Grand Island 31 Faidley, 68803 Yes x❑ NO ❑
<br />10 RACE leg.. While Black Amencan Indian TIT ANCESTRY
<br />rS0ecilyl
<br />le q. Italian. Mexican, German. etc) 12 MARRIED ❑ WIDOWED 13 NAME OF SPOUSE /It -fe grve Marne, name)
<br />etc I ISpecrtyl
<br />White
<br />German NEVER DIVORCED r
<br />❑ MARRIED Lorraine Ksionzek
<br />IAa 'JSUA L OCCUPATION rGrvekMddt— kdohedunhg --1
<br />It nrr rlo kle, even 11 ra,rredl
<br />IGb KINDOFBUSINESSI N DUSTRY 15 EDUCATION I Speclly only highest grade compleledl
<br />Ofice Administrator
<br />Elementary or Secondary '0 12) Cortege ' - --
<br />Ammunition
<br />1
<br />NAME FIRST MIDDLE LAST 117 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />:16FA:T�HER
<br />Henry H,
<br />Hansen Dorothy UNK Plambeck
<br />i6 WAS DECEASED EVER IN US ARMED FORCES'
<br />--
<br />.a INFORMANT NAME -
<br />Yes n� unx.l III yes give war and tlates of services,
<br />C $.lode ❑ Pending
<br />No N/A
<br />Lorraine Hansen
<br />19b INFORMANT MAILING ADDRESS
<br />(STREET OR R F D NO CITY OR TOWN STATE. ZIP) -
<br />1822 West 15th Street,
<br />Grand Island, Nebraska 68803
<br />20 EMBA IM�R- SIGNATURE B LICENSE NO
<br />)
<br />21a ME THOD OF DISPOSITION 21b DATE i 21c CEMETERY OR CREMATORY NAMEn�Iete
<br />`
<br />�' -- /" -
<br />a Burial ❑ Removal August 14, 200 St. Francis Catholic
<br />- 22a FUNERAL HOME NA 61F
<br />1 210 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Kleine Funeral Home
<br />❑ = -hon ❑ oonalo, j
<br />Ashton Nebraska
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.
<br />CITY OR TOWN STATE. ZIP( -
<br />321
<br />IMMEDIATE CAUSE -
<br />Grand Island Nebraska 68803
<br />°.r�o n... ,. .,.� .... ...� ... -... -
<br />STATE
<br />175 l7�
<br />M
<br />q
<br />tai 1;_.�-',; �`'�- L -�..•
<br />-
<br />rarer r 0elween on 1
<br />ealn
<br />/L..� V. i.. '.
<br />DUE 70, OR AS{�CONSEO N E OF
<br />l l )"
<br />„(
<br />Acr,oem � Undetermined
<br />ery
<br />Intal pe -o
<br />onset n n =ah,
<br />I/ ,
<br />0
<br />l/
<br />bl
<br />r ^
<br />J� /
<br />.�
<br />)tween
<br />L v (�
<br />A
<br />O
<br />DUE 70 OR ASpSCON:SS�EOU t O
<br />,
<br />C $.lode ❑ Pending
<br />C t�
<br />Interval be tw ee n onset a a Heal h
<br />I t
<br />`
<br />1
<br />HOm�CiOe InveShgdirOn
<br />�
<br />CL"-,r
<br />OTHER SIGNIFICANT CONDITIONS - Conditions
<br />PART
<br />contributing to the death but not related
<br />PART III',( MALE WAS THERE A
<br />2 AUTOPSY
<br />25' WAS S REFERRED i0 MEDICAL
<br />II
<br />PREGNAN \ IN THE FAST 3 MONTHS?
<br />28b TIME OF DEATH
<br />EXAMINE OR CORONER'
<br />$
<br />o�
<br />27b DATE SIGNED ('
<br />Day YrJ
<br />27E TIME OF DEATH
<br />(Ages 10 54 Yes Na
<br />Yes No
<br />�
<br />Yes 7 No I
<br />STATE
<br />175 l7�
<br />M
<br />26a
<br />26b DATE OF INJURY /MO.. Day Yr.J
<br />26, HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />„(
<br />Acr,oem � Undetermined
<br />r ^
<br />J� /
<br />.�
<br />M
<br />C $.lode ❑ Pending
<br />26e INJURY AT WORK
<br />261 PLACE OF IN URY AI home farm street laclory 25G LOCATION STREET OR R F D NO CITY OR TOWN
<br />office budOrng. er SDecilyl
<br />HOm�CiOe InveShgdirOn
<br />Yes No
<br />❑ ❑
<br />rS r,•� l
<br />'
<br />27a DATE OF DEATH 111O D y vr.; -
<br />12Ha 117E SIGNED IMO Day 1r;
<br />28b TIME OF DEATH
<br />4-4
<br />N
<br />$
<br />o�
<br />27b DATE SIGNED ('
<br />Day YrJ
<br />27E TIME OF DEATH
<br />$ r
<br />26c PRONOUNCED DEAD lMo Day. Yr I
<br />20d. PRONOUNCED DEAD (He,,,
<br />rn 0
<br />vX
<br />) V
<br />i- z..�` -Io
<br />o N -o
<br />To the best of my knowledge
<br />death occurred at
<br />the time
<br />M
<br />I'27d date and olace due to the
<br />cause(sl staled. /
<br />tL�.MV'�'v- IV,
<br />° ¢� j f
<br />-
<br />268 On the basis of examination and or —v hg.uon, in my opinion death occurred at
<br />mr, lime. date and place and 0ue 10 the cduselsl slated.
<br />�: w
<br />Signature and Title(► • -� t
<br />® ISM Title)
<br />29 DO TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30 :a HA DRGAPI OR TISSUE
<br />DONATION
<br />nature and ►
<br />—
<br />SEEN CONSIDERED' 30A WAS CONSENT GRANTED'
<br />0 �l `
<br />❑ YES ❑ NO UNKNOWN
<br />YES YES
<br />N�) I VES nIC
<br />U
<br />III 31 NAM AND ADDRESS OF CERTIFIER 'PHYSSSIIC��CIiAN. CORONERS PHYSICIAN OR! GUNTY ATTORNEY. T1ne or P-q, -
<br />William J Landis MD 2444 W. Faidle
<br />Ave. Grand Island Nebraska 68803
<br />Q
<br />32a REGISTRAR
<br />32b DATE BLED BY REGISTRAR /Mo.. Day Yrl
<br />a)
<br />— - - - -- — - 9'J'' a''�
<br />r � AUG 2 0 2001
<br />oa 0
<br />STATE
<br />175 l7�
<br />M
<br />
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