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<br />
<br />
<br />lot Twenty.Dna (21) in Block One (1), In Island Acres Number Two (2), being a replat of lot One (1), Two (2), Three (3), Five (5), Six (6) and
<br />Seven 171, In Island Acres, a subdivision in the City of Grand Island, Hall County, Nebraska
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASJAA.,-~TATE
<br />DEPARTMENT OF HEALTH~ IT CERTIFI.ES THE BELOW ,TO,,' "'i" ",qoPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE,. ., ";HEALTH
<br />BUREAU OF VITAL STATISTICS. WHICH IS THE L"
<br />VITAL RECORDS. ....... t.i~~-..
<br />200607285 ~r"i~"tK:.
<br />
<br />$",50
<br />
<br />SEP
<br />
<br />4 '1991
<br />
<br />
<br />DATE OF ISSUANCE
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />,.
<br />
<br />STAtE OF NEBRASKA - DEPARTMENT 0;: HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />t:lONALD
<br />.. CITY -'NO ST-'TE OF BIRTH (1IIII>I'n V.S.A, n.m. country)
<br />
<br />William
<br />
<br />HANSEN
<br />
<br />
<br />3. 0-' TE OF OE-' TH (Month, Oay. Y.a,)
<br />
<br />1. OECEOENT . N-'ME
<br />
<br />FIRSl
<br />
<br />MIOOlE
<br />
<br />LASl
<br />
<br />Garden Cit , Kansas
<br />1. SOCIAL SECURITY NUMBER
<br />
<br />
<br />Male
<br />
<br />08-17-91
<br />
<br />50. AGE. loa! BI~l\doy
<br />IY".I 5b. MOS.
<br />61yV
<br />
<br />OAYS 50. i'lOURS'
<br />,
<br />I
<br />
<br />6. OATE OF BIRTH (Monlll. Day. y..,)
<br />
<br />07-13-30
<br />
<br />512-24.,.9943
<br />
<br />~ 0 In",,'ion' Xl ER/O"",,~.", 0 00.0
<br />OTHER: 0 NU<alng Ho,,", 0 R..idenoe 0 Ot~e, (S!",<ify)
<br />Be. CITY, TOWN OR WCATION OF OEATH 8<1. INSIOE CITY LIMITS
<br />GRAND I S LAND (S!"'<i!yYO.O'NO)
<br />, YES
<br />
<br />
<br />90. CITY. TOWN OR lOC-'TION
<br />
<br />8b. FACILITY. Name (If not ifJ8liMion. 9;'18 ,t"" /1M number)
<br />ST FRANCIS MEDICAL CENTE
<br />
<br />
<br />ge. RESIOENCE . STATE
<br />
<br />NE
<br />
<br />HALL
<br />
<br />RD
<br />
<br />90. INSIDE CITY liMITS
<br />(SpeCify Y.. or No)
<br />YES
<br />
<br />WHITE
<br />
<br />11, ANCESTRY le.g.,ltalltn, MtJican. Germafl. 81e.)
<br />(Spocily) Arne .
<br />rlCan
<br />
<br />13. N-'ME OF SPOUSE (II ",ile. g/.. maidim ..mo)
<br />ARLYCE N Mays
<br />
<br />1... USUAL OCCUPATION (Gi.e klfl(lol worlr done during moot
<br />of tIJIOIking life. .VIffl if f.lirlf1)
<br />. MaI}ager
<br />
<br />Conoco Court Motel
<br />
<br />COlIOilO )1.4 Or 5'1
<br />
<br />16. FATHER. NAME
<br />
<br />
<br />FIRST
<br />
<br />MIOOlE
<br />
<br />LAST
<br />
<br />17. MOTHER. MAIOEN N-'ME
<br />
<br />FIRST
<br />Sarah
<br />
<br />MIOOlE
<br />
<br />LAST
<br />
<br />Carl
<br />
<br />Ramsey
<br />
<br />lB. WAS OECEASEO evER IN U.S. -'RMEO FORCES?
<br />IYes, nO, Or unk,l '"..flll.'fiva war and 9at" of Hrvicp}...
<br />Yes Kore ~- 5-53/3-l8-~~
<br />
<br />201>. OA TE
<br />
<br />)STREET OR R.F.O. NO" CITY OR TOWN, ST-'TE, ZIPI
<br />Arlyce Hansen 1316 Isle Rd. Grand Island, Ne. 68801
<br />
<br />20<1. lOCATION
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />Westlawn Cemetery
<br />22. FUNEAAl HOME. NAME -'NO -'OORESS
<br />
<br />Grand Island, Nebraska
<br />
<br />)STREET OR R.F.D. NO" CITY OR TOWN, STATE, ZIP}
<br />
<br />AU
<br />C -I.
<br />1.1 4...I lUJoil..(
<br />OUE TO, OR -'S A CONSEQUENCE OF,
<br />
<br />pfel-Butler-Geddes 1123 W. 2nd Grand Island, NE. 68801
<br />
<br />~.
<br />
<br />Irnttrval between onMI and daaU't
<br />
<br />~
<br />
<br />Interval between onMit and ~&Ih
<br />
<br />OUE TO. OR AS -' CONSeQUENCE OF:
<br />
<br />Intetv.' betwHn onat an~ ~am
<br />
<br />
<br />OTHER SIGNIFICANT CONDITIONS. CoOdlllooo conlrlbuMg 10 doa!h b" not ,.I.,ed
<br />PART
<br />II
<br />
<br />25. WAS CASE REFERREO TO MEOIC-'l
<br />EXAMINER OR CORONER?
<br />(Spocilytf6or No)
<br />
<br />260. ACCIOENT, SUICIOE. HOMICIOe, UNOET., 2Bb. OATE OF INJURY (Mo.,O'y, Y,.)
<br />OR PENDING INVESTIGATION (Spoci/y)
<br />
<br />280. INJuRY AT WORK
<br />(Spocl/y Y.a or NO)
<br />
<br />STREET OR R.F.O. NO.
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />21.. O-'TE OF OEATH
<br />
<br />280. OA TE SIGNEO (Mo., O'y, Y,.)
<br />
<br />2Bb. TIME OF OEATH
<br />
<br />~!i
<br />Ih~
<br />~n
<br />
<br />28c. PRONOUNCEO DEAD (1.10.. D<ly, Yr.)
<br />
<br />2Bd. PRONOUNCED OEAO (HOI./')
<br />
<br />28e. On me basis of examination and/or in....stigatlon, 111 my OpiniOn d..th oceurr~ .1
<br />the 11th", dlitt .nd P'.c. and due 10 tIW caUMI'llral~.
<br />
<br />:lOb. WAS CONSENT GAANTEO?
<br />
<br />o yeS
<br />
<br />~NO
<br />
<br />ncis Medical Center Grand Island, Ne. 68801
<br />
<br />32L FlEGISlAAR
<br />
<br />
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