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Z n ......':t-. c: :t>- <br /> O 0 ;lI; ~$ ::3 :z -I N <br /> ~ :I: n = -i rTl <br /> m > ~ -c -< 0 it <br /> n (;l 0 <br /> '" :c ,....... 0 ....., C) <br />I\.) i 0 .." ;1 <br />s .." ~ Z <br />S 0 :x:: rrl <br />en rn -0 :t>- O'J <br />S rn fl ::3 r ::0 <br />.p.. 0 ~ r l> <br />...... ~ (f) (f) <br />w c..0 ;;><; <br />en l> <...) ...... <br /> c..0 ............'~...' <br /> -..J CI) (1)2 <br /> CI) 0 <br /> <br /> <br /> <br />WHEN THS COPY CARRIES THE RAISED SEAL OF THE NEBRASM.HeAL'PJ!NIf!!JI@M!lSERVlCES <br />SYS1E'A( "" CERTIFIES THE BELOW TO BE A mUE COpy OF THE ORIG/NJfL R5C1JRIUJR,fHLE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL &iifTli1iesS~CTiOtl..WJtICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. t7-,~;'~H'~~=-=:.,c:~ <br />-DATE OF ISSUANCE 200604136 s:-:M...~ _:& 08_..1."'._' .;.~-. cO <br />APR 16 1998~~~~!J::/:r~:. <br />LINCOLN, NEBRASKA HEAL TH NIp HU.~'d!!ilf!I16ES #STEM <br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUMAi.!:iEilMcis:FiNM'!tE ~ SUPPORT <br />VITAL STATISTICS-:';;~ ~,- - ..::,.=- <br />CERTIFICATE OF DEATH=.:o;:s,,~,::----:~=- <br /> <br />~ <br />(1 <br />~ <br /> <br />l _ <br />" .- <br />'" <br /> <br />1 DECEDENT _ NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />2 SEX <br /> <br />3. DATE OF DEATH fManlh. D(ly. YfXJrJ <br /> <br />Harold <br /> <br />Werner <br /> <br />Christensen <br /> <br />Male <br /> <br />April 07, 1998 <br /> <br />4. CITY AND STATE OF BIRTH iN tu)/in USA.. ""me CO<dI"v1 <br /> <br />Sa, AGE - last Birtl'lday <br />(V,..) <br /> <br />69 <br /> <br />UNDER 1 VEAR <br />5b. MOS. DA VS <br /> <br />UNDER t DAY <br />5c, HOURS' MINS <br /> <br /> <br />6. DATE OF BIRTH (Month Day. Yt!larJ <br /> <br />Linn Grove, Iowa <br />7. SOCIAl. SECURTiV NUMBER <br /> <br />January 01, 1929 <br /> <br />st!. FACiliTY. Name <br /> <br />{If not inst1tutian. give $treet find nI.lmberJ <br /> <br />8. PLACE OF DEATH <br />HOSPITAL: 0 <br />o <br />o <br /> <br />Inpatient OTHER. 0 NurSIng Home <br />ER 0""","." [i] ReSidence <br />DOA 0 o.her (SpeC/lvl ~. <br /> <br />481-32-5375 <br /> <br />2905 North Webb Road <br /> <br />10 RACE .(8.9., Whitfl. BlaCk, American Indian. <br />etc.IISoecltyl <br />Whitc <br /> <br />11. ANCESTRY le,g., Italian. M8)(ican. German, Mel <br />ISpec,fyl <br />American <br /> <br /> <br />9d. STREET AND NUMBER 1h1C1~ Zip C_I <br /> <br />ge. INSIDE CITY LiMn's- <br /> <br />Be. CITY TOWN OR LOCATION OF DEATH <br /> <br />ad INSIDE CITV liMITS <br /> <br />Grand Island <br />9.. RESIDENCE - ST A T~ <br /> <br />Nebraska <br /> <br /> <br />Yes ~ No D <br />13. NAME Of SPOUSE (1f wIIB. givs maider' namel <br /> <br />14a. USUAL OCCUPATION (Give kind of work done dun'ng most <br />of working 1/18. even If retirea) <br /> <br />Civil En ineer <br /> <br />16. FATHER - NAME FIRST MIDDLE <br /> <br />City of Grand Island <br />LAST 17 MOTHER <br /> <br />Lydia Glienke <br /> <br />15. EDUCATION (Specify only hlgnes1 grade completed) <br />E,emel, or Seconaary 10-121 COlleglll' .~ or oS.1 <br /> <br />Walter <br /> <br /> <br />MIDDL~ <br /> <br />MAIDEN SURNAME <br /> <br /> <br />Lena <br /> <br />Hensel <br /> <br />L dia Christensen <br />ISTQEET OR RFD NO. CITY OR TOWN. STATE, ZIP) <br /> <br />:?1b. DATI; <br /> <br /> <br />, ~Bl,lrl~J <br /> <br />D ~Iemoval <br /> <br />04/11/1998 Elk Township Cemetery <br />21d CEMETERY OR CREMATORY LOCATION ~ CITY OR TOWN <br /> <br />STATE <br /> <br />o Cremation 0 Donation <br /> <br />Linn Grove, Iowa <br /> <br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. liP) <br /> <br />1123 West Second Grand Island, Nebraska, 68801~5899 <br />23. P~RT IMMEOlATE CAUSE j ~Nm <br /> <br />VE:.... ~s;,~C'.... <br /> <br /> <br />Inl.'vaI3~"'" <br /> <br /> <br />~V\ Ca.-V\ CfL,1 <br /> <br />Interval between onsel and dealt' <br /> <br />, I ~.~, J.e:t!.~i.ih-- <br /> <br />(c) <br />PAFl'f OTHER SIGNIFICANT CONDITIONS. Cmdilions contributing 10 the death but no4 ~erated <br /> <br />" <br /> <br />2Sa. <br /> <br />26b. DATE OF INJURY IMo.. Day. Yt.j 26c. HOUR OF INJURY <br /> <br /> <br />I <br />25 WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER' <br /> <br />NO~_. <br /> <br />o Accidenl D Undeli:!rmtnet;l <br />o SUicide 0 Pending <br />o HQmicide Investigation <br /> <br />260. INJURY AT WORK <br />V.. D No 0 <br /> <br />26g, LC-:;A TION <br /> <br />STREET OR R.F.D. NO. <br /> <br />CITy OR TOWN <br /> <br />STAff. <br /> <br />27a. DATE. OF OE:ATH (Mo" Day. Yr.J <br /> <br />28a. DATE SIGNED rMo.. Day. Yr., <br /> <br />28b TIM!;: OF PEA TH <br /> <br /> <br />;:;-~ <br />l~ ~ <br />E I ~ <br />~f5 <br /> <br />~~ <br /> <br />" ~ <br />::~ ~ <br />!i ~ ~ <br />8$~~ <br />11~=- <br />~~8 <br />t,l <3 <br /> <br />M <br /> <br />2Be PRONOUNCED DEAD iMo OBY. YI./ <br /> <br />8:18 p.m. <br />2ijd. PAONOUNCED OEAO (HOUri <br /> <br />M <br /> <br />i~ <br /> <br />31 <br /> <br />~, ~III"'.' <br /> <br />32b DATE FILED BY REGISTRAR IMo.. Day. Yt.j <br /> <br />APR 14 1998 <br /> <br />LEGAL DESCRIPTION: Lots One (1) & Two (2), in Schumann Subdivision, Hall <br />County, Nebraska <br />