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WHEN TENS COPY CARFWS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM R CERTNES THE BELOW TO BE A TRUE COPY OF THE ORIGNALR ON FU WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST _ _ iN 7CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS 'r
<br />DATE OF ISSUANCE
<br />�IA1! O[t
<br />6/22/2004 20040? 18 - R
<br />ASS+rAZE ab4
<br />LINCOLN, NEBRASKA HEAL TICAND IIISERNIC893 S EM z
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND AR1RfAPi#,F$V1fNA1 A ASP `.
<br />vTrAL sTAmncs
<br />CERTIFICATE OF DEATi+= _ / 5 W 47
<br />t. DECEDENT -NAME FIRST MIDDLE LAST
<br />n n
<br />3..DRTE OF'DEATFi S/MpnM. DAY. Year/
<br />Harold H. Hennin s
<br />Male.
<br />12, 2004
<br />4. CITY AND STATE OF BIRTH /anot kr USA.. name countryl
<br />Sa. AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1. DAY,
<br />6. DATE OF BIRTH (Monts. Day. Year/
<br />M
<br />(Vrs.l Sb.
<br />C n =
<br />v
<br />CIA cn
<br />p
<br />�.
<br />O�
<br />Aril 28, 1918
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />505 -48 -7307
<br />HOSPITAL ® Inpatient OTHER_: ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />rn D y
<br />cam-
<br />M
<br />O
<br />84. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes FE No ❑
<br />Hall
<br />9a RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (IncluNbg Zip CoCel
<br />N)
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1434 N. Pipe 68803
<br />Yea ® No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g., Itallan. Mexican. German, etc)
<br />12. a MARRIED ❑ WIDOWED
<br />13, NAME OF SPOUSE (// wife. give maiden name)
<br />ft.) (Specify)
<br />White
<br />O T
<br />NEVER DIVORCED
<br />M ,
<br />v
<br />O
<br />N
<br />15. EDUCATION (Specify only highest grade completed)
<br />rri
<br />O
<br />r
<br />Farmer
<br />Agriculture
<br />8th Graded
<br />M
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Peter Hennings F
<br />Frieda Muhs
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes, no, or unk.) (If yes. give war and dates of services)
<br />No I - - - - --
<br />Louise Hennin s
<br />CD
<br />1434 N. Piper, Grand Island Nebraska 68803
<br />20.E E - SIGNATURE 8 LICENSE Fr
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c,
<br />CEMETERY OR CREMATORY NAME
<br />® Burial ❑ Removal
<br />May 15, 2004
<br />Westlawn Memorial Park
<br />22a. RAL HOME - N C711,
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin ston- Sondermann F.H.
<br />E] Cremation ❑Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road Grand Island Nebraska 68803 -4050
<br />23. IMMEDIATE CAUSE ( TER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (cll I Interval between onset and death
<br />PART
<br />L I
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and
<br />1
<br />I
<br />- I
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />Lot Four (4) in Island Acres Number Three (3), being a Replat of Lot Fifteen (15) in
<br />Island
<br />III IF FEMALE WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />Acres, a Subdivision in the City of Grand Island, Hall County, Nebraska.
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />it
<br />(Ages
<br />WHEN TENS COPY CARFWS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM R CERTNES THE BELOW TO BE A TRUE COPY OF THE ORIGNALR ON FU WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST _ _ iN 7CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS 'r
<br />DATE OF ISSUANCE
<br />�IA1! O[t
<br />6/22/2004 20040? 18 - R
<br />ASS+rAZE ab4
<br />LINCOLN, NEBRASKA HEAL TICAND IIISERNIC893 S EM z
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND AR1RfAPi#,F$V1fNA1 A ASP `.
<br />vTrAL sTAmncs
<br />CERTIFICATE OF DEATi+= _ / 5 W 47
<br />t. DECEDENT -NAME FIRST MIDDLE LAST
<br />Z, SEX s -
<br />3..DRTE OF'DEATFi S/MpnM. DAY. Year/
<br />Harold H. Hennin s
<br />Male.
<br />12, 2004
<br />4. CITY AND STATE OF BIRTH /anot kr USA.. name countryl
<br />Sa. AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER 1. DAY,
<br />6. DATE OF BIRTH (Monts. Day. Year/
<br />(Vrs.l Sb.
<br />MOS. DAYS
<br />Sc. HOURS' MINS.
<br />Grand Island, Nebraska
<br />86
<br />Aril 28, 1918
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />505 -48 -7307
<br />HOSPITAL ® Inpatient OTHER_: ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b. FACILITY, Name (Mnot insmufion, give street and number)
<br />St. Francis Medical Center
<br />❑ DOA ❑ Other(Spec,/vi
<br />ec. CITY. TOWN OR LOCATION OF DEATH
<br />84. INSIDE CITY LIMITS
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes FE No ❑
<br />Hall
<br />9a RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (IncluNbg Zip CoCel
<br />9e INSIDE CITY LIMBS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />1434 N. Pipe 68803
<br />Yea ® No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g., Itallan. Mexican. German, etc)
<br />12. a MARRIED ❑ WIDOWED
<br />13, NAME OF SPOUSE (// wife. give maiden name)
<br />ft.) (Specify)
<br />White
<br />(Specify)
<br />I German /American
<br />NEVER DIVORCED
<br />M ,
<br />Louise Luebbe
<br />14a, USUAL OCCUPATION (Give kind of work done during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Specify only highest grade completed)
<br />of ivorking INe. even if reared)
<br />-, 21 College 11.4 or 5 -I
<br />Farmer
<br />Agriculture
<br />8th Graded
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Peter Hennings F
<br />Frieda Muhs
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT - NAME
<br />(Yes, no, or unk.) (If yes. give war and dates of services)
<br />No I - - - - --
<br />Louise Hennin s
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />1434 N. Piper, Grand Island Nebraska 68803
<br />20.E E - SIGNATURE 8 LICENSE Fr
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c,
<br />CEMETERY OR CREMATORY NAME
<br />® Burial ❑ Removal
<br />May 15, 2004
<br />Westlawn Memorial Park
<br />22a. RAL HOME - N C711,
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin ston- Sondermann F.H.
<br />E] Cremation ❑Donation
<br />Grand Island, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road Grand Island Nebraska 68803 -4050
<br />23. IMMEDIATE CAUSE ( TER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (cll I Interval between onset and death
<br />PART
<br />L I
<br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and
<br />1
<br />I
<br />- I
<br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death
<br />I
<br />I
<br />(c)
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but nth related PART
<br />III IF FEMALE WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />it
<br />(Ages
<br />10 -54) Yes No
<br />Yes No
<br />Yes D No
<br />26a.
<br />26b. DATE OF INJURY (Ma. Day. Yr.)
<br />26c. HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />7 Accident ❑ Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />Lp
<br />26f. office OF INJURY -St home, farm, sheet. factory
<br />building ( pscity)
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Yes ❑ No ❑
<br />27a. DATE OF DEATH /Mo. Day. Yr./
<br />28a. DATE SIGNED (Mia. Day. Yr.)
<br />28b TIME OF DEATH
<br />Y
<br />M
<br />8,
<br />G
<br />27b. DATE SIGNED (Mo.. Day. r)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo.. Day. Yr.)
<br />28d. PRONOUNCED DEAD (Hour)
<br />9& i
<br />a�6Z
<br />X (noon) 12: OOP
<br />$�°
<br />M
<br />8
<br />a
<br />B o8
<br />27d. To the y kno ge. death occurred at and place and due to the
<br />28e. On the basis of examination and, or investigation, in my opinion death occurred at
<br />7dale
<br />,,,cause(sl stated.
<br />c��
<br />the time, date and place and due to the causes) stated.
<br />(Signature and Title) ► %
<br />(Si ature and Title) ►
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />fJ
<br />X 1:1 YES RN ❑ UNKNOWN I/
<br />❑ YES � NO ,�
<br />❑ YES a NO
<br />31. NAME AND ADDRESS F;OP CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Prin -
<br />X Dr. Gordon J. Hrnicek, M.D., 729 N. Custer, Grand Island, NE 68803
<br />32a REGISTRAR
<br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr./
<br />MAY 18 2004
<br />11 9
<br />
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