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<br />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 DEPkRTU,ENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAI,_.DROSI`POIY'FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE /
<br />�� 1 � 1987 STANLEY 5._000PER,DZRECTOR
<br />LI N, EBRASKA BUREAU OI' 'V,17 i :.$�ATISTICS
<br />200504250
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />DECEDENT —NAME FIRST
<br />MIDDLE LAST
<br />SEX
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />Janice
<br />A ._.
<br />Y
<br />T3ecembei
<br />Hansen
<br />2Fema e
<br />RACE— (e.g., White, Black, American
<br />ORIGIN /DESCENT(e.g..Italian, Mexican, AGE —Lost Einhde,
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />DATE OF BIRTH (Mo,. Day, Yr.)
<br />MOS. DAYS HOURS , MIN$.
<br />Indian, ek.) (Specify)
<br />German,
<br />etc.) (Specify) (Yrs.)
<br />4 White
<br />a. American 6a, 52
<br />6b. 6t:.
<br />March 11, 1935_
<br />CITY AND STATE OF BIRTH (If not in U.S.A.,
<br />CITIZEN OF WHAT COUNTRY
<br />I MARRIED, NEVER MARRIED,
<br />NAME OF SPOUSE (If wife, give maiden name)
<br />ame country)
<br />�9.
<br />WIDOWED, DIVORCED (Specify)
<br />I
<br />1prand Island, Nebraska
<br />U.S.A.
<br />1oMarried
<br />(Jack L. Hansen
<br />SOCIAL SECURITY NUMBER
<br />USUAL OCCUPATION
<br />(Give kind of work done during most
<br />KIND OF BUSINESS OR INDUSTRY
<br />12507 -36 -3970
<br />of working life,
<br />113a.
<br />even ifrefired)
<br />Homemaker
<br />113b, Domestic
<br />ICOUNTYOFDEATH
<br />Hall
<br />14a.
<br />CITY, TOWN OR LOCATION OF DEATH
<br />INSIDE CITY LIMITS
<br />HOSPITAL OR OTHER INSTITUTION — Name (If not in either, IF NOSP. OR INST. Indiear. DOA.
<br />Grand Island, Nebraska
<br />(Spec Yes or No)
<br />tes
<br />gives 1 by Q.rpati_ /Em., Rm., Inpve.n, ISp «il,)
<br />MIM West LaMar --
<br />146.
<br />14d
<br />RESIDENCE — STATE
<br />COUNTY
<br />CITY, TOWN OR LOCATION
<br />STREET AND NUMBER
<br />INSIDE CITY LIMITS
<br />Hall
<br />1,,,.Grand Island
<br />115.2007 West LaMar
<br />�s;e?es or Na)
<br />,Jiebraska
<br />1Sb
<br />d
<br />FATHER - NAME FIRST
<br />MIDDLE LAST
<br />MOTHER - MAIDEN NAME FIRST MIDDLE lA
<br />Melvin
<br />- Poore
<br />Beulah - Hessel
<br />16
<br />17
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />INFORMANT — NAME — RELATIONSHIP — MAILING ADDRESS (STREET OR 1l .F D. NO., CITY OR TOWN, STATE, ZIP)
<br />(T• yr uk III y.r. 9 "- v and da.r of ..l
<br />143
<br />1B
<br />19.Jack L. Hansen 2007 W. LaMar Grand Island, Ne. 68803
<br />BURIAL, Cremation, Removal
<br />DAT
<br />CEMETERY OR CREMATORY —NAME
<br />LOCATION CITY OR TOWN STATE
<br />Dec. 10,
<br />1987
<br />20., Burial
<br />lob.
<br />��. Grand Island City Cemetery
<br />god. Grand Island Ne. _
<br />E ER— SIGNATURE d LICENSE NO
<br />y 7 l
<br />FUNERAL HOME —NAME AND ADDRESS (STREET OR R.F.D� NO_ CITY OR TOWN, STATE, Zlry
<br />LAC'24
<br />3(/
<br />Butler- Geddes 1123 W. 2nd Grand Island, Ne.. 6880.
<br />I
<br />22Apfel-
<br />DATIF OF DEATH (Mo., Doi, Yr.)
<br />DATE
<br />SIGNED (Me. Day, Yr.)
<br />HOUR OF DEATH
<br />iW
<br />Z.
<br />g�
<br />23a. December 7 1987
<br />_�ao
<br />24a.
<br />24b.
<br />M
<br />BATE SIGNED (Mo., Doy, Yr.)
<br />HOUR OF DEATH
<br />DEAD PRONOUNCED
<br />DEAD (Hour)
<br />L"
<br />n. t PRONOUNCED
<br />s_
<br />_..m.. _
<br />e�Co (Mp..
<br />Day, r..).
<br />1V
<br />2sb.December 8 1987,_
<br />123,, 9:30 M
<br />„ZZ� 24c.
<br />2Ad.
<br />T• rhv bnr v1 my kn lodg., death •ee. r,
<br />M rime, don v.d law end due to th.
<br />rlr. bath el •xeminari.n and /v. inwtrig Han, i. my epi.m. d.oth . ..... d or
<br />��
<br />a (50 On
<br />• f
<br />F`
<br />c su•.(.) .ror.d.
<br />ti0ro e rhv
<br />` 1240.
<br />It. dare and plat► and due w the ce W.) trar.d.
<br />tad, (Sipnelun and Tine) B•
<br />u
<br />(Sipnafun end N0.)
<br />23. Dr. G.L. Hrnicek 729 North Custer Grand Island, Nebraska 68803
<br />REGISTRAR DATE RECEIVED BY REGISTRAR (Mo., Day. Yr.)
<br />26a- (sip.ow..) ■ 26b. DEC 1 5 1987
<br />� 23. IMMEDIATE CAUSE (ENTER ONLY ONE C PER LINE FOR (o /, (b), AND (c)) Int..vvl b.n.vvn . Irr end death
<br />PART
<br />_,lol __.... .._... ...._ Inr•nal bHw•.n enter end death
<br />DU TO, OR AS A CONSEOUENCE OF: �IJ W
<br />46)
<br />DUE TO, OR AS A CONSEQUENCE OF: Inror.al b•r.. ... .... r nod death
<br />Ic1
<br />PART SIGNIFICANT CONDITIONS- C•ndirront wnrrib.rinp ro death b.., -w-land PART III. IF FEMALE, WAS THERE A AUTOPSY WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY IN THE PAST 7 MONTHS? (Spvdly Y., •. No) EXAMINER OR CORONER
<br />11 _ (Sp.cify Y.. or N.)
<br />Yes 0 No 28. 29.
<br />ACCIDENT, SUICIDE, HOAUCIC UNDEY., DATE OF INJURY (Ma., Doy, Yr.l HOUR Of INJURY DESCRIBE HOW INJURY OCCVRRE
<br />W PENDING INVESTIGATION. !Sp «ify)
<br />300. 30b. ]Oc. M 30d.
<br />IEUURY AT WORK PEACE OP IN)URY- At he.re• lot., M.N, fnab y. LOCATION STREET OR 1'F 0, N.. CITY OR TOWN STATE
<br />(Specify Y« or N.) •Ifke Is.ildi. 9. N[. (SP «ify)
<br />Its- 130C 130o,
<br />LEGAL DESCRIPTION: LOT TEN (10) AND LOT ELEVEN (11) IN BRACH'S SECOND ADDITION TO THE
<br />CITY OF GRAND ISLAND, HALL COUNTY, NEBRASKA
<br />
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