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WHEN TMS COPY CARIBFS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERd/OES -=: -_ SYSTEM, IT CERTF/ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECS -iI�H_ THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE '= A EY S. COOPER SEP 0 4 2002 200314673 ASSISTANT ATER ISTRl1Ft LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SY,gfklfl� STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FIN'CFA3SkJ T VITAL STATISTICS `2 10010 o CFRTIFiCATF OF DFATP I . DECEDENT - NAME FIRST MIDDLE LAS? 2 SEx 3. DATE OF DEATH !M,. r nav Year/ Raymond C. Hansen Male August 23, 2002 d. CITY AND STATE OF BIRTH ld not h U SA.. name country/ Sa. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Monts Dav Year/ MOS DAYS 5c. HOURS MINS Rockville, Nebraska IVm) 80 5b U Janua 22 1922 7. SOCIAL SECURTIV NUMBER 8a PLACE OF DEATH 508- 127602 HOSPITAL: Inpatient OTHER: ® Nursing Home ER Outpatient Residence 8b. FACILITY -Name /p not msliwaon. give street and number) Beverly Health Care - Lakeview DOA �I Other 15-4, 8c. CITY. TOWN OR LOCATION DEATH Bd. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island Yes ®Nd Hall 9a. RESIDENCE - STATE 110. 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Code/ 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 11614 N. Elm Street 68801 Yes ® No RACE - (e.g.. White. Black. American Indian. 11. ANCESTRY le.g.. Malian. Mexican. German, etcl 12. ® MARRIED ❑WIDOWED 13. NAME OF SPOUSE IN wife give maiden name) etc.) fSoeclfy) White (Spec tyl American NEVER D IVO ACED Nora Sorensen 1 MARR1 14a. USUAL OCCUPATION /Giv work e kind of done during most 14b KIND OF BUSINESS INDUSTRY 15. EDUCATION (Speclty, only highest grade completed) of working life, even it retired) Dock Worker Trucking Elementary or Secondary 10 -12) College 11 -4 or 5.1 7 16. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Chris F. Hansen Frieda T. Plambeck 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yes. no or unk.) (If yes. give war and dates of services) I No I Nora Hansen 19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIPI 1614 N. Elm Street, Grand Island, NE 68801 - S ATURE 6 LIC E NO. 21 a. METHOD OF DISPOSITION 21b. DATE 2tc. CEMETERY OR CREMATORY NAME DMB,AL,MER �.�/I•G� G #1071- ® Burial ❑ Removal Au ust 28, 2002 Kelso Cle a. FUNER4 kk0 E -NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE All Faiths Funeral Home Howard County, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIPI 2929 S. Locust St. Grand Island, NE 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND (GI Interval between onset and dean PART lal W d2avA & DUE TO. OR AS kCONSEOUEPCE OF Interval between onset and death (b) DUE TO. OR AS A CONSEQUENCE OF Interval between onset and deal, (c) OTHER SIGNIFICANT CONDITIONS . Conditions contributing to the death but not related PART PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL e PREGNANCY IN THE PAST 3 MONTHS EXAMINER OR CORONER' (Ages 10 -54) Yes No Ves No �( Yes No 26a 26b. DATE OF INJURY (Mo.. Day. OF INJURY 26d. DESCRIBE HOW IN„JRV OCCURRED Accident � Undetermined Tc�R M Suicitle Pending 26e. INJURY AT WORK 261. PLACE OF INJURY - At home, farm, street. factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Inv¢SIIga1KKt ❑❑ Yes No ❑ o ice buldirg, etc. lSpeciry/ 27a. DATE OF DEATH (MO. Day. Yc1 28a. DATE SIGNED [Mo., Day. Yr) 28b TIME OF DEATH r August 23, 2002 i M $ m E }U > r 27b. DATE SIGNED /MW11002 / 27c. TIME OF DEATH 28c. PRONOUNCED DEAD IMO. Day. Ycl 28d. PRONOUNCED DEAD /Four) n i 8g° August 3:40 P. E N °�� M g M 27d. To the best of my k wled Bt tinned at the time, d to and place and due to the 28e. On the basis of examination and or investigation, in my opinion death occurred at a o ° causefsl staked. - Me time. date and dace and due to the causels) stated. (Signature and Tide (Si nature and Tine) ► 29. DID TOBACCO USE CON U TO TH TH? 30.a HAS ORGAN OR TISSUE DONATIOZBEE ONSI DERED? 30.b WAS CONSENT GRANTED? YES NO F] UNKNOWN YES O El YES NO Dr. John A. Wago er, 800 41ph St., Grand Island, NE 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR JMo.,faay.2'r1 ft I SEP EXHIBIT "A"