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-WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR
<br />VITAL RECORDS. - - -
<br />DATE OF ISSUANCE ,A�
<br />AUG n ,y r STANLEY S. COOPER, 9- IRECTOR
<br />�;9�
<br />LINCOLN, NEBRASKA BUREAU OF-VITAL STATISTICS
<br />200208856
<br />STATE OF NEBRASKA — DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE OF DEATH IMoi Day Yen!
<br />Chris Hans Rasmussen Sr.
<br />Male
<br />Julv 19 1992
<br />e, CITY AND STATE OF Bi IN ref m U5 A. Marne county)
<br />Si AGE Lail Ba1May
<br />OR PEN 1NVESTIWTION (Sperry!
<br />�,IC,d� 7/19/92 06 0
<br />1
<br />6. DATE OF BIRTH IAbMA Day, Y04)
<br />56 N09.1 OAY9
<br />x.IauRS mM1s.
<br />St. Paul, Nebraska
<br />(YrsI
<br />78
<br />270. DATE OF DEATH (MO.. Day. Yc)
<br />April 30, 1914
<br />7. SOCIAL SECURITY NUMBER
<br />1s,. PLACE OF DEATH Mwsn*s, ❑ Indictment L ER,Ou1PMMa ❑ COA
<br />506 -09 -4475
<br />i OTHER ONuol Nome ❑RNkkand, ZOaur (SPeci
<br />BS FACILITY -Name ItrcY imet va Ares, and mrmW)
<br />Bc. CITY, TOIAN OR U,,uk i OR OF DEATH Ed. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />St. Francis Medi Center
<br />(Slaki YK w NP)
<br />Grand Island Yes
<br />Hall
<br />9.. RESIDENCE STATE UNTY
<br />Sc. CITY, TOWN OR LOCATION
<br />9d, STREET ANO NUMBER p/KYVdvp Zip Ccole)
<br />Be. INSIDE CITY LIMITS
<br />(N; VK or Nol
<br />Nebraska Hall
<br />Grand Island
<br />223 E. 18th 68801
<br />Yes
<br />10. RACE - e 1„ Vii Black Amt
<br />11. ANCESTRY (aq.BMaM, Meucar. GurrMrl, s,c.l 12 MARRIED,NEVER MARRIED,
<br />13. NAME OF SPOUSE Irl nM, pm mean nernaJ
<br />nc) MI
<br />{Mite
<br />(SpnMl WIDOWED. DIVORCED /5pecM)
<br />American �� Married
<br />Irene Ott
<br />tea USUAL OCCUPATN)N (Giw Field one dlnng moet
<br />d mondi Ithe even a nehi 11
<br />Hb. KIND OF BUSINESS INDUSTRY
<br />y��
<br />ENmenlary or S anden (0-121 I CdlegB 11 -4 or 5.1
<br />a�,''
<br />Truck DriveT1
<br />Moving &Storage
<br />10th Grade
<br />16. FATHER NAME FIRST MIDDLE LAST
<br />17. MOTHER MAIDEN NAME FIRST MIDDLE LAST
<br />Soren Rasmussen
<br />Marie NMN Staal
<br />113WAS DECEASED EVER IN U.B. APAIRCES?
<br />19. INFORMANT - NAME - MAILING ADDRESS (STREET OR R.F.O. NO. CITY OR TOWN, STATE, 618801
<br />(VK. W, or InkJ (II yeti. gM v6 ales d N/Ked Yes WWII 10- 42/145
<br />Irene Rasmussen, 223 E. 18th, Grand Island, Ne.
<br />2oa. BURIAL CrematnJeorr al
<br />RE
<br />EM, CEMETERY OR CREMATORY -NAME god. LOCATION CITY OR TOWN STATE
<br />Domatdm Burial
<br />ly 23, 1992
<br />Grand Island City Cemetery Grand Island, Nebraska
<br />2 MBALMER � SIGN U 6 LIGEN
<br />22, FUNERAL HOME - NAME AND ADDRESS (STREET OR RF.D NO.. 11,Y OR TOWN. STATE, 2111 68801
<br />03
<br />Livin stoat- Sondermann 505 W. Koenig, Grand Island Ne.
<br />n PAW '/ v IF^. F ^vmr Inc unuuc ncn u.�-rvn
<br />A
<br />Papal oxidation on,M am deatn
<br />1
<br />Internal bar«Nn omen and deem
<br />OTHER SIGNIFICANT CONDITIONS - CandlbnA cpmrlbueng to death but not related PART 111 IF FEMALE. WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />2a, ALIIDPSY
<br />ISpBCM YK or No)
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />PART
<br />11
<br />Yes 2 No ❑
<br />A r Q
<br />pk" YBS or No) A r
<br />He ACCIDENT, SUICIDE. HOMICIDE. UNOET. 26t. PATE OF INJURY IMO.Dey, Ycl 26c. NO iJ<OE INJL1 .V 26] DESCRIBE OW INJURY OCCURRED
<br />O Seated in car in closed garage With
<br />OR PEN 1NVESTIWTION (Sperry!
<br />�,IC,d� 7/19/92 06 0
<br />A engine running.
<br />26,1 INJURY AT WORN 261 . PLACE OF INJURY Al Mme, tart. attract. lector, 261. LOCATION STREET OR HF.D. NO CITY OR TOWN STATE
<br />,$, YK Or )AP) Pence building an c. Styke l
<br />x10
<br />223 E. 18th, Grand Island, NE
<br />garage at home
<br />270. DATE OF DEATH (MO.. Day. Yc)
<br />Es, DATE SIGNED (MO.. Day YF1
<br />2131. TIME OF DEATH
<br />/yy
<br />�Ll , /
<br />Sal
<br />M
<br />.
<br />E
<br />pLL
<br />{y�
<br />S'{
<br />210. DATE SIGNED (MO., Day. Vy
<br />2)c. TIME OF DEATH
<br />2BC PRONOUNCED DEAD 6MO. Day Yr./
<br />28d PRONOUNCED DEAD (Hour 1
<br />/
<br />€Q
<br />8
<br />a
<br />27d Tome Nn of my xnawMd, deW occurred Y a Ome aM place and due Io ME
<br />2Be On In. be,., 01 examination and or inveelipaMn, in my denim death =urred at
<br />]�3aW Myrat /// '
<br />S
<br />me time, date and dace and due 10 me cauri ala1N.
<br />IS ni and Tdkl� r - ' -
<br />1s nnura and Tdle
<br />26X, NO TOBACCO USE CONNTTRIBUT O THE DEATMA
<br />9Ja. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />001 WAS CONSENT GRANTED?
<br />J YES Al No ❑ UNKNOWN
<br />D YES
<br />AND
<br />❑YES pi
<br />,
<br />91` NeuF AND ADDRESS OF CE TIER I(PHHYSICAN, CORONER 5 PHYSICAN OR COUNTY ATTORNEY)
<br />(Type or Pi
<br />( ( C`p
<br />ra C <1 �'C �-YGf -L.C1 ZS �GL470 �I �OJ O
<br />32a. REGISTRAR
<br />13Zo DATE FILED eV REGISTRAR Al pey Yrl
<br />JUL 2 3 1992
<br />/ v
<br />a
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