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200204826 3®8.8 stet
<br />STATE OF NEBRASKA— DEPARTMENT OF f 'S2 2i%ja
<br />Bureau of Vital Statistics tjoi7t?, L� ® 3CERTIFICATE OF DEATH `-'-, . 1. , as
<br />DECEASED —NAME FIRST -Doti LAST
<br />�
<br />KENNETH LEWIS JAIXEN
<br />Fm
<br />��rl.
<br />ale
<br />2. 8-2� � .. ••
<br />RACE WHIITI, NEGRO, AMERICA. INDIAN,
<br />ETC. 1 SPECIFY I
<br />AGE —CAST
<br />31 RIND AI Ail'
<br />UNDER 1 YEAR
<br />UNDER 1 DAI
<br />DATE OF BIRTH 1 MONTH, DAY.
<br />ITAR I
<br />COUNTY OF DEATH
<br />1
<br />I MOS
<br />DAIS
<br />NOURS
<br />MIN.
<br />10i to
<br />6 -3 -1931
<br />ball
<br />E
<br />SR46
<br />SE
<br />,,
<br />CITY, TOWN, OR LOCATION OF DEATH
<br />INSIDE CITY LIMITS
<br />SPtCITY YES OR NO
<br />HOSPITAL OR OTHER 04STITUT ION —NAME (IF NOT IN EITHER, GIVE STR(el AND NuM3FR )
<br />Grand Island III,
<br />Yes
<br />Lutheran Hospital
<br />,d
<br />STATE Of BIRTH I U Not IN U.S.A., NAME
<br />CITIZEN OF WHAT COUNTRY
<br />MARRIED, NEVER MARRIED,
<br />SURVIVING SPOUSE I IF wife, GIVE "Aloe. NAME 1
<br />COUNTRY
<br />Nebraska
<br />U.S.A.
<br />WIDOWED, DIVORCED (s►fC11Y l
<br />Married
<br />�11 Romana E.
<br />,.
<br />),
<br />Termus Jaixen
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION IGIVE KIND OF WORK DON! DURING MOST Or
<br />KIND Of BUSINESS OR INDUSTRY
<br />WORKING flit, EVEN If RETIRED 1
<br />12. 505 -28 -0044
<br />I31 Welder 1.'tt'
<br />In. Machinery flew Rolland
<br />RESIDENCE —STATE
<br />COUNTY
<br />CITY, TOWN, OR LOCATION
<br />INSIDE CITY urns
<br />STREET AND NUMBER
<br />I'lebraska
<br />1,,, Ball
<br />G rand Island
<br />II3dtUrr YesR NQ 1
<br />114. 2 710 W. 10th
<br />IIR.
<br />I3(
<br />FATHER —NAME FIRST .loot( LIST MOTHER—
<br />MAIDEN NAME FIRST ..Doti LAST
<br />Gehard - -- Jaixen 1IS11
<br />Emma -- Ilanke
<br />ISR
<br />Id WAS DECEASED EVER IN U.S. ARMED FORCES? INFORMANT— NAME — RELATIONSHIP— MAILING ADDRESS (STREET oR R.F.D. NO , CITY O46Cg8d1*TE, ZIP)
<br />`Y4' m7runk" °w"' 9-yT? "4"9;ndj= 1'1°� -'52' „R I•Irs. Romana Jaixen, Wife, 2710 W. 10th, Grand Island, 14
<br />Pr PART 1. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LINE FOR (o), (b), AND (c)(
<br />11ETw(eN ONSn ANO DeA
<br />�B IMMEDIATE CAUSE
<br />Uff 10, 04 ITS A CONSEQUENCE OF:
<br />CONDITIONS, Ir ANY,
<br />WHICH GAVE RISE TO
<br />IMMEDIATE CAUSE IDI, DU! TO, OR AS A CONSEQUENCE OF:
<br />STATING iNE UNOlR
<br />LYING CAI 1A31
<br />(c)
<br />PA 11. OTHER SIGNIFICANT CONDITIONS: CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED
<br />PART 111. If FEMALE, WAS THERE A
<br />AUTOPSY,
<br />If YES WEBF FINDINGS CO
<br />TO CAUSE GIVEN IN PART No)
<br />PREGNANCY IN THE PAST 2 MONTHST
<br />1 Yet OR OI
<br />SIDERED IN DF TTIRMINING CAU
<br />0/ DEATN
<br />YES O NOD
<br />),..
<br />IN.
<br />ACCIDENT, SUICIDE, HOMICIDE,
<br />DATE OF INJURY ( MONTH, DAY, YEAR
<br />HOUR
<br />HOW INJURY OCCURRED IENTER NATURE Or IN)URT IN FART 1 OR PART 11, IffM 131
<br />OR UNDETERMINED I SPECIFY I
<br />1
<br />2011.
<br />201.
<br />20(.
<br />M. 20d.
<br />INJURY AT WORK
<br />PUCE Of INJURY AT HOME, FAB., STREET, FACTORY,
<br />LOCATION 1 Snfet oR R.F.D. NO., CITY oR TOWN, STATE)
<br />I SPECIFY YES 011 NO 1
<br />0 C! SLOG., ETC. 1 SPECIFY I
<br />209.
<br />201
<br />I1.
<br />2Bt
<br />CERTIFICATION— MONTH DAY YEAR MONM DAY YEAR
<br />AND LA3r SAY/ NIA /HER ALIVE ON
<br />I DID/ D NOT vIEVj i "II
<br />DEATH OCCURRED AT THE PLACE, ON THE
<br />/HYSICIAN: �Y •TO
<br />1 A1Tl HOED THE J •/
<br />r0NiH DAY YEAR
<br />SODY K`
<br />IHOURI OAt[, AND, TO M! N
<br />Of AT RHO LEDGE, O
<br />`/'
<br />2111. DECEASED FROM / / 711. i I
<br />'l
<br />21t. Z(/ ��
<br />jid.
<br />y
<br />2L11. ,� (r� M. TO ME CAUSEISI STATE
<br />CERTIFICATION— MEOICAL EXAMINER OR CORONER: off M( 3ASls or ME HOUR Or DEATH
<br />THE DECEDENT WAS PRONOUNCED DEAD
<br />EXAMINATION Or ME ROOT AND /OR THE INVESTIGATION, IN MY OPINION,
<br />HON/ *AT YEAR HOUR
<br />De ATM OCCURRED ON THE DATE AND DUE TO THE CAUSTICS) STATED.
<br />7211. M.
<br />2 /1'l V
<br />221 0 Q F
<br />CERTIFIER —NAME HYPE OR PRINT)
<br />SIGNATURE DEGREE OR Arse
<br />DATE SIGNED t NM, DAY, YEAR(
<br />2211. W.L. Fowles M D 22►.
<br />tk.
<br />INAILIEVN AUURC»— LERFIFFER E1,
<br />:2d 727 ii. Custer Grand Tqland, Npbraqka ARAM
<br />BURIAL, CREMATION, REMOVAL CEMETERY OR CREMATORY —NAME LOCATION CITY oR rowN STATE
<br />(SPECIFY I
<br />2411 Burial 23► i'lestla�Tn Memorial Park :Et. Grand Island idebraska 6880
<br />DATE (MONTH, DAY, TIAlu FUNERAL HOME —NAME AND ADDRESS I STREET OE R.F.D. NO., CITY oR TOWN, STATE, 2101
<br />2" 8-24- 2sA fel- Butler- Geddes Funeral Home Grand Island, NE ,68801
<br />EMBAIJri SIG ATU 8 ENS( O. REGISTRAR— SIGNATURE —%1 //f /,/J�� DATE RECEIVED BY LOCAL REGISTRAR 77
<br />76b(
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br />STATE DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br />A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH
<br />IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />A
<br />DIRECTOR "OF VITAL STATISTICS AND ASSISTANT SPATE REGISTRAR
<br />LINCOLN, NEBRASKA Issued August 29, 1977
<br />
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