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<br /> WF�N TWS COPY CAlZIZES Tl�RA/SED SEAL OF THE NEBRASKA HEALTH AND HUMAALS€R�CES
<br /> SYSTEI{�IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE OR/Q/NAL RECO_ ! �``
<br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEII�VITAL STAT/STICS� =� � .=�
<br /> THE LEOAL DEPOSITORYFOR VITAL RECORDS - - -- =
<br /> DATE OF/3SUANCE _ ����' _=_ -
<br /> �,������ ' - - - - - - _
<br /> DEC 3 1999 9 9 i 118 8 � ��-�� ___ __
<br /> ASS/STAIV��TE REG/STRpR=,-= _�
<br /> UNCOLN,NEBRASKA HEALTHAND HUMAI�ERYlCB$.SYS�IIf _-_=
<br /> STA1E OF NEBRASKA-DEPARl'MENf OF F�AI.1'H AND Hi]MAN SERVi ^ ' �-�'_�=
<br /> C�NCE''�:S�POIbT
<br /> Vtl'AL STATIST[CS -- � .�= , '-- - -
<br /> ��_�:
<br /> CERTIFICATE OF DEATH --�-.
<br /> i.DECEDENT-NAME FIRST MIDOLE LAST 2.SE% 3.�DATE OF OEATN /AbnM.�Day.Yeail
<br /> Virginia Katherine Jensen . Female November 22, 1999
<br /> a.CiTV ANO STA7E OF BiR7H /Hnd h U.S.A..name epmM/ 5a.AGE-last BinhEay UNDER t YEAR UNDER 7 DAV 6.DATE OF BIRTH lMOnlh.Day.Year/
<br /> Gothenburg, Nebraska ��'S.' 79 se Mos. onvs Sc.HOURS' MINS.
<br /> March 16, 1920
<br /> 7 SOCIAI SECURTIY NUMBER 8a.PLqCE OF DEATH
<br /> 505-18-2902 HOSPITAL � Inpatient OTHER � NurS��qHOme
<br /> 8D.FACILITV-Name /NnvfinSMUflon,givesbeelaMnum6gr) � EROulpaUent � Resitlence
<br /> St. Francis Medical Center ❑ �A ❑ a���.�,ry,
<br /> 8c.CITY TOWN OR LOCATION OF DEATH BG.INSIOE CITY IM.tT$ � 8e,CQ�NTY pF(j�117►1 �- � � . y_ ..._, .
<br /> , . _ . ...,. . : . _.e�- .. ..�._.._..;e.
<br /> Grand Is1an�.. .P_..___"�..,��_ 'Yas �] No ❑ Hall
<br /> 9a.RESIOENCE-STATE 9b.CWNTV 9c,CITV,TOWN OR LOCATION 9tl.STREET AND NUMBER /InclWingZipCode/ 9e WSIDE CITV uMi7S
<br /> Nebraska Hall Grand Island 2720 W. 5th St. 68803 �es � No❑
<br /> �0.RACE-le.g..Whlle.Black.Americao Indian. 11.ANCESTRV Ie.g..flalian.MeKican.German,etcl 12�MAfiR1ED ❑WIDOWED 13.NAME OF SPOUSE p/wi/e,yive maiden name�
<br /> etcJ IScec�ryl ISDeciyl
<br /> White American NEVER DIVORCED Arthur Jensen
<br /> tU.USUALOCCUPATION /G�vekindo/workdanedunigmpsf 14b.NINDOFBUSINESSINOUSTRV 15.EDUCATION �SpeciyontyMghestgradecomplele0�
<br /> d hvrkNg li/9.Bven il IBlired� .
<br /> Homemaker EbmeMa7 w SecaWary lo-i2� ' Cdlege n e o�5-�
<br /> Domestic lOth Grade �,�
<br /> 16 FATHER-NAME FIRST MIDDLE lAST 17 MOTHER FIRST MIDOLE MAIDEN SURNAME
<br /> Seth Sexton Helber Edith Pearl Dorn
<br /> 18.WAS DECEAS�D EVER IN US.ARMED FORCES7 19a.INFORMANT-NAME --
<br /> IVes np.a ank.� Ilf yes.give war arld tlates d services)
<br /> No ------- Arthur Jensen - Husband
<br /> 19D.INFORMANT MAILING ADDRESS ISTREEi OR R.FD.NO.,pTV OR TOWN.STA7E.ZIP� -
<br /> 2720 W. 5th St. , Grand Island, Nebraska 68803
<br /> Z0.E AL ER-S T 8 UCE NO 21 a.METH00 OF qSPOSi7iOni 2�D.DATE 21c.CEMETERV OR CREMATOFV�NAME
<br /> � ��/�� �B��,a� ❑Aemo�a� Nov. 26, 1999 Westlawn Memorial Park �
<br /> 22a.FUNEML E-NA E 21C.CEMETERY OR CREMATORV LOCATION CI7V OR TOWN S7A7E
<br /> Livingston-Sondermann F.H. �`'""°'�" �°onat�' Grand Island Neliraska � �
<br /> 22b.FUNERAL HOME ADDRESS (STREET OF R.F.D.NO..CITY OR TOWN.STATE.Z�P� . - "�-- �
<br /> 601 N. Webb Road, Grand Island, Nebraska 68803-4050
<br /> 23. M�AMEDIATE CAUSE IENTER ONLV ONE CAUSE PER LINE FOR la�.�b�.ANO�c�) � Inlerval behveen onse�anc�Pair
<br /> PART
<br /> �' ,a, Cardio ulmonar i ;-l-
<br /> DUE T0.OR AS A CONSEOUENCE OF: I nterval behxeen onsei and oeam
<br /> i
<br /> Ibl I
<br /> I
<br /> DUE TO.OR AS A CONSEOUENCE OF: I Imerval EeMeen onsefano oeam
<br /> '
<br /> I�I �
<br /> i
<br /> OTHER SIGNIFICANT CONOITIONS-Conddions corXiibuUng b Ihe tlealh Dul nd relate0 PART III IF FEMALE.WAS THERE A 2d.AUTOPSV 25.WAS CASE REFERRED TO MEDiCAL
<br /> PART PREGNANCV IN THE PAST 3 MONTHS7 EXAMINER OR COfiCNER�
<br /> II
<br /> �Ages 10-Sd) Ves No Yes No Ye5 No
<br /> 2�� 26b.DATE OF INJURV /MO..Day.YiJ 26t.HOUR OF INJURV 26d.DESCRIBE HOW INJURY OCCURRED
<br /> � AccitleM � Untle�e�min9d M
<br /> � Smcitle � Pentlmg 269.INJURV AT WORK 261.PLACE OF,INJURV-At ho, ,larm.street.fattay 26g.IOCATION STREET OF R.F.D.NO. CITY OR TOWN STA iE
<br /> a ❑ office buldng ett lSpecAy�
<br /> � Homiatle Invest�galion ygs No
<br /> 27a.DA7E OF DEATH /AIO..Day.YrJ 28a.DATE SIGNED /bfo..Day.nJ 28D.TIME OF DEATH
<br /> �S� � M
<br /> �u`''i 27b.DATE SIGNED (MO..Day.YcJ 27c TIME OF OEATH `��T 2BC.PRpNOUNCED DEAD /MO..Oay,Yc/ 28d.PRONOUNCED DEAD /HOUrI
<br /> �� �<
<br /> ��'° _� ia�ovember 22 1 • � M
<br /> g� 27tl.To the Ce51 of my knowleAge,thalh occurretl at Me time,Ea1e aM place and due lo Me M °�� 2Be.On Mg bssis d examinatron i 'n igation,in y opnion Ceath occurr at
<br /> causelsl stated. c� � time,date and ce use�s�sta
<br /> IS nalwe and Title� S�naWre and Title
<br /> 29.DID TpBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATpN BEEN CONSIDERED? 30.b WAS C SENT GRANTED?
<br /> � � YES � NO � UNKNOWN "\ � VES 1 [� NO � � VES � NO
<br /> `YY YY
<br /> 31.NAME AND ADDRESS OF CERTIFIER(PHVSICIAN,CORONER'S PHYSICNN OR CWNTV ATTORNEVI lType w Pn'MJ
<br /> �llen Totzke all Coun Attorne 11 E s G
<br /> 32a.REGISTRAR . 32b.DATE FILEO BV REGISTRAR /MO.,Day. r.J .
<br /> �
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