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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISE,? SEAL QF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINALJlEC(JRii~ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSiies-SECTION:iYHK:H (S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . -i?'7J-c-._'-_l~-:--}\:'~:'~-~:'
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<br />DATEDF/SSUANCE ~~
<br />
<br />JUL 1 8 2006 A~~="-'~=-~-'-~~':
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<br />LINCOLN, NEBRASKA HE~~-"i_.__rMMi~RV"i.ES
<br />-~~ ~_;..:.~-,-7~~< _:'~==.' .."-
<br />51.ATE OF NEBRASKA.- DEPARTMENT OF HEALT. H AND HUMAN SERVICES FI~Af<<;E'AN5.'..'~~.'~;()~E-O'~'::'~ ">17.' () . 0 .
<br />__.____._-u.--- CERTIFIC~TE Of_DEATH~'~~~Y-L . ~
<br />I. DECEDENT'S-NAME (Flrsl. Middle, Last, SuUi,) 2. SEX 3. DATE OF DEATH (Mo., Day, Y'.)
<br />Alan J. Hoffman Male July 7, 2006
<br />
<br />4~CITY AND STATE OR TER~iTORy,~FOREIGN COUNTRY OF BI~~}H; AGE.Lost B~rlhday 5b. UNDER I YEAR 5c. UNDER I DAY 6. DATE OF-;IRTH {~~::- Day, y;:i -.--.
<br />(Yrs.) MO..TDAYS . HOURS I MINS..
<br />Carroll, Iowa 56
<br />~---~--
<br />
<br />200608664
<br />
<br />&
<br />
<br />--~,-
<br />-= 'II; ( ......,:J.~'... ''; > ."'.~.'~
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<br />Francis Skilled Care Nursing
<br />
<br />N~vemb~~ 28, 1949l
<br />
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<br />~ Inpalienl Qlli~R; IX Nursing Home/LTC 0 Hosplco Faclllly I
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<br />U ER/Oulpalienl 0 Docodent's Homo
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<br />o iD\ ---~ ~lh.'(S~--===- ~ ~
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<br />8d COUNTY OF DEATH
<br />Hall
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<br />=rg~~::;W~sland _.- - -- -- I
<br />_- ~=L~T~;~O~; -ri:S~~:ClTY~IM~~
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<br />lOb. NAME OF SPOUSE (Firs!, Middl., L.s!, Sufllx) If wile, glvo mold.o name.
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<br />Ba. P~ACE OF OEATH
<br />
<br />I:JQSflI~L:
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<br />Bb. FACILITY.NAME (If 001 ioslllulion, give slre.1 and numbor)
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<br />80. CITY OR TOWN OF DEATH (Includo Zip Code)
<br />Grand Island, 68803
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<br />_.._.__._-~
<br />9.. RESIDENCE-STATE 9b. COUNTY
<br />Nebraska Hall
<br />_.J'''_''''__''~'
<br />9d. STREET AND NUMBER
<br />2608 w. COllege
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<br />lOa. MARITAL STATUS ATTIME OF DEATH IXMarriad 0 Nev., Married
<br />
<br />U Married, bul '.paraled 0 Wldowod :J Dlvorcod 0 Un.nov,"
<br />
<br />Kaylene Gayle Hanousek
<br />
<br />11. FATHER'S-N~~l(~r~~-~~Ie,- Ho~~~n --S;;;;I~] 12. MOTHER'S-NA~o::~~----M~d.le, H~o~;~~i~~
<br />"":~~:~:~:lrNu~.S)~~D~;RCES? Give:ele;OI::rv'oelf';.~~i:;~~M'E H?ffman m- _~---.- ~~~~TION:HIPTO~Ec::m:-'
<br />
<br />15. METHOD OF OISPOSITION. ....~~~~.. ER.~IGNATU.R. E /lJj /I .' 16b LICENSE NO. 160. DATE (Mo" Oay, Yr. )
<br />lXBurlal o Do02llon (. i:lI.i"CLCf,....'(ej UAAA~,-~~- _ Ju_~ 10~ 20~.__
<br />OCramalioo 0 Eotombment 16d.CEMETERY, CREMATORY OR OTHER l-OCATION CITY fTOWN STATE
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<br />OOlher{Sp.olly) Westlawn Memorial Park Cemetary
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<br />Grand Island, Nebraska
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<br />170. FUNERAL HOME NAME ANO MAILING ADDRESS (Slreel, Clly or Towo, Stal.)
<br />Curran Funeral Chapel 3005 South Locust Street , Grand
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<br />-~,,-,-,-,---,-,,~,-
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<br />...~-~--,----,"--'
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<br />ill. PART I. Enter the cha.ln..9ay~.rl.!s--djSBases.lnJlJrjes, of compl1cationa.~-that directly caused the daa1h. DO NOT enler terminal events such as cardiac arrest,
<br />---
<br />respiratory arrest, or ventricula.r fibrillatIon wUhoul showing the etIology. DO NOT ABBREVIATE. Enhtr only one caU8e on a line, Add addaiorlBlllno5lf nec8ssary.
<br />
<br />onsel10 death
<br />I
<br />~ Zt!~l;i _
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<br />1 onS811o death
<br />I
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<br />S.qu.oliollyIIstoondition.,If (b) A!....C.IU.. ....___ .---.~-
<br />any, '..ding to tho ,",uae listed ----DUE TO, OR AS A CONSEQUENCE OF:-'-'''- --'-" I onsel i~tieilIh--'-
<br />onllno8. I
<br />Entertho UNDERLYING CAUSg /t (/1 (
<br />(dl..... or Injury thai initialed (0) IF
<br />
<br />
<br />~:~:::::,"~~:~:::;:o:::~:=:." ."""",,.~:~"""~"~'"~ ,_ =- -. .t:':':~m","-. ..l
<br />
<br />--d"(/"/.r" I f:l1Cfu.t$ vi {fIt (v/; ."!""j aVY!c,,! {,,',/d..e ~:~";":''''"J\
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<br />20 IF FEMAI r 21. MANNFR OF DEATH 21b IFTRANSPORTATION INJURY 210 WAS AN AUTOPSY PERFORMED?
<br />.Natural 0 Homicide 0 Driver/Operator
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<br />U Passenger
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<br />o Ped.slilan
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<br />IMMEDIATE CAUSE:
<br />
<br />IMMEDIATE CAUSE (Floal
<br />disease or cond"lon resull1ng
<br />10 death)
<br />
<br />(~).
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />.__".~( rIP ~.dtt 1;,:
<br />
<br />12<:' t~1l1 {4ft ( c /'"
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<br />o Not pr.gnant wllhin past y.ar
<br />o Pregnanl al time of death
<br />o NOI pregnanlj but pregnant within 42 days 01 dealh
<br />
<br />DYES
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<br />IXNO
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<br />o AccidentO P.nding Invostigallon
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<br />o Sulcid. 0 Could nol be delermlned
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<br />21 d. WERE AUTOPSY FINOINGS AVAILABLE TO
<br />
<br />o Olher (Speoify)
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<br />COMPLETE CAUSE OF DEATH?
<br />o Y~S 0 NO
<br />
<br />o Nol pr.goonl, bul pregnanl43 days 10 1 ye., b.'ore daalh
<br />o Un.nown II pr.gnant wilhin Iho past year
<br />---.----T22b.TI
<br />22a. DI\IE OF INJURY (Mo., Day, Yr.) CME OF INJUR:
<br />
<br />
<br />----. ---r-......
<br />22d.INJURY AT WORK? .2. 2a. DESCRIBE HOW INJURY OCCURRED
<br />DYES 0 NO
<br />221loCi\TiOfj 6'ri~~ifT1'lttT &~MB~J\, APT. NO.
<br />
<br />220. PLACE OF INJURY.At hom., la,m, stro.l, laotory, ollic. building, con"'uollon .it., eto. (Speolfy)
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<br />CITY/TOWN
<br />
<br />._------1
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<br />SWE ----;!~~DF. ---I
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<br />2~f.D;;TE OF DEATH (Mo" Day, Yr.) ..-/ ~ tdC-----l ~~.~
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<br />;tJb. DATE SIGNED {Mo., Day, Yr.)""" . ~c TIME OF DEATH .--- ~ ~ ~
<br />, \ .., 2. (J /. . '-1.. m 'li.!I. < ~
<br />V E~~Z
<br /><lll't--O
<br />2~d. To the besl 01 my Knowllldg., doalh oocOlred 0 lime, dolo .od pl.ce ~ uJ ~ 24.. On Iho basi. olexaminalion andlor inv.Oligalion. In my opinion death OGOUrrod al
<br />I and due to tho cau~1i1 sl.lad"'(&I.gn~lur. ~i.)'" ..' D ~ 0 thoUme, dale and place aod due 10 tho cause{s) staled. {Signalur. and Title)1I"
<br />'/ v ~ ~rr.u
<br />, / ,/:/(,.".t 1'1/ 8 ~
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<br />. ~.Dli)TOBACCO USE CONTRIBUTETOT E DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />f
<br />o YES ~O 0 PROBAB~Y 0 UNKNOWN 0 YES lK NO . NOI Appliu.blo_it26. is N9__ 0 Y\:S ri NO .
<br />-Zi:NAME,i'ii-iliio AODRESS OF CERTIFiER (PHYSiCiAN, CORONER'S PHYSiCiAN OR COUNTY ATTORNEY) . (Type or p,i~'-
<br />Gary L. Settje M.D. 2116 W. Faidley Ave. Suite 400, Grand Island, NE 68803
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<br />24b. TIME OF OEATH
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<br />24a. DATE SIGNED (Mo., Ooy, Yr.)
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<br />m
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<br />240. PRONOUNCED DEAD (Mo., Dey, Yr.)
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />m
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<br />26b. WAS CONSENT GRANTI'.O?
<br />
<br />28a. REGISTRAR'S SIGNATURE
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<br />
<br />28b. DATI'. FILEO BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />JUL 1 4 2006
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