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<br />wHEN rHts copy CARRIES THE RAISED SEAl,; OF THE NEBRASKA HEALTH A.ND;HUMAN SERVICES
<br />SYS7EM, IT CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIt1#N'Ai;~~fILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VlTALJlfA'R$1'IC$~TF.:.'WHICH IS
<br />THE UiGAL DEPOSITORY FOR lIITAL RECORDS.C;,c ~"Cflt
<br />
<br />
<br />DA,.'M'Z'; 200700398 H..g~NT~T~jj~
<br />
<br />LINCOLN, NEBRASKA HEAL rHANDHIJM!4N .~yicE!C':JYSTEM
<br />STATE OF NEBRASKA- DEPARlMENT OF HEALnt AND HYMANS~VICEi'FJNANcaND SUPPORT
<br />VITAL STATISTICS' .. ...' ._.,.7?~
<br />CERTIFICATE OF DEAm:';:: _'_ '-'O:-:;Y~.-
<br />
<br />1. DECEDENT. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />lAST
<br />
<br />2. SEX
<br />
<br />J. DATE OF OEATH (Month.Oay. Y"'J
<br />
<br />Elba, Nebraska
<br />.. 7. SOCIAL SECURTlV NUMBER
<br />
<br />~ 505-07-3839
<br />
<br />) 8~. FACllITV . Namo (N"'" ""liM;"" g(ve.""", and nu"",",J
<br />
<br />~ St. Fran~~~~edical Center
<br />~ 8e. CITY. TOWN OR lOCATION OF DEATH
<br />
<br />5a. AGE - Last Birthday
<br />
<br />IVS4
<br />
<br />uNDER, VEAR
<br />5D. MOS DA VS
<br />
<br />Male
<br />
<br />UNDER 1 DA V
<br />SO. HOURS' MINS.
<br />
<br />
<br />1999
<br />
<br />RayYOC>nd
<br />4. CITV AND STATE OF BIRTH IN ""'in USA na"",eo,mtryl
<br />
<br />F.
<br />
<br />Hansen
<br />
<br />18,
<br />
<br />1914
<br />
<br />88, PLACE OF DEATH
<br />HOSPITAL: []
<br />D
<br />D
<br />
<br />Inpatient OTHER. D Nursiog Home
<br />ER OulPO~onl D Atsldence
<br />DCA 0 01'" (Speclfyl
<br />
<br />White
<br />
<br />
<br />ad. INSIDE CITY liMITS 110. COUNTY OF DEATH
<br />
<br />Grand Island,
<br />98. RIOSIDENCE. STATE
<br />
<br />Yes [Xl No
<br />
<br />Hall
<br />
<br />((neluding Z;p C_,
<br />
<br />90. INSIDE CITY liMITS
<br />
<br />Nebraska
<br />10. RACE. (e.g.. White, Black. American Indian.
<br />o'ellSoocily1
<br />
<br />Yos []J No D
<br />(N ""10. give "",den _I
<br />
<br />E. Vir inia Rentschler
<br />
<br />_ 14a. uSUAL OCCUPATION fG/VBkindofwori(donedurlngmostl J-f3
<br />) of workmg life. ,ven if ffltiffJdJ 'i I
<br />
<br />" Farmer
<br />i 16. F ATHER. NAME FIRST MIDDLE
<br />
<br />i Hans B.
<br />
<br />_ 18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />(Yes. no. or un~,l 1Il yes. give war &00 dates of services)
<br />WWII 1942-1945
<br />MAILING ADDRESS
<br />
<br />Hannah
<br />
<br />(unk)
<br />
<br />MAlDEN SURNAME
<br />..,/
<br />Hansen
<br />
<br />LAST ..I
<br />Hansen
<br />
<br />17. MOTHER
<br />
<br />MIDDLE
<br />
<br />
<br />
<br />Hansen
<br />
<br />P _ O. Box 54
<br />20 EM8AlMER. &IGNATURE & ",CENSE NO.
<br />
<br />Cairo Nebraska
<br />21 a M<THOD DF DISPOSIT'O' 21 ~ DATE
<br />
<br />Not Embalmed
<br />22a. FuNERAL HOME. NAME
<br />
<br />D Burial 0 R@(f1oval
<br />
<br />
<br />21 e, CIOMET"RV OR CREMATORY NAME
<br />Central Nebraska Cremation
<br />
<br />210 CEMETER
<br />
<br />CITY OR TOWN
<br />
<br />
<br />ATE
<br />
<br />Godberson Mortuary ~cramaMn D Do,,,,nc
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITV OR TOWN, STATE. ZIP)
<br />
<br />Gibbon, Nebrasla
<br />
<br />P. O. Box 10, 719 Front St., Gibbon, Nebraska 68840
<br />23 IMMEDIATE CAUSE ~ lENT lOR ONl V ONE CAUSE PER liNE FOR '"IIDI. AND (ell
<br />P~R~ 0cuJle ~rJJ F~
<br />
<br />),r: Interval between onsel and dealt'1
<br />
<br />I
<br />I
<br />I
<br />
<br />&-w uJ1L
<br />
<br />i
<br />
<br />
<br />ln1erval between onset ancl cleath
<br />
<br />Interval ~tw"1'\ ons8t 81M ottal*l
<br />
<br />lei
<br />
<br />p~ia;;xIF~N~ITIO~l;Piu~;P~i ,"hi'
<br />
<br />2& 26b DATE OF INJURY (Mo., Day. yo 26e HOUR OF INJURV
<br />
<br />'J)!' DATE OF DEATH (Mo Day y,,,
<br />
<br />~.. \.. qq
<br />
<br />DATE SIGNED (Mo.. Day. Y'I
<br />
<br />
<br />26g. lOCATION
<br />
<br />STREET OR RF.D. NO,
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />0 Accident 0 UnMterml(\80
<br />0 SUIcide 0 PendIng 28. INJURV AT WORK
<br />0 Homu:;IM Investigation vesD NoD
<br />
<br />2S8 DATE SIGNED (Mo.. Day y, I
<br />
<br />28b TIME OF DEATH
<br />
<br />C):l3Q
<br />
<br />"a !;;
<br />h~>-
<br />!i:!~~
<br />1l~=>
<br />",~8
<br />'" '
<br />
<br />M
<br />
<br />- =<
<br />. s ~
<br />~ Iii
<br />
<br />:=.~
<br />
<br />
<br />e. TIME OF DEATH
<br />
<br />28< PRONOUNCED DEAD (Mo D.y, y,,,
<br />
<br />2ad. PRONOUNCW DEAD (Hou"
<br />
<br />M
<br />
<br />M
<br />
<br />288'. On the basis of examination ancl'Of investigation, in my opinion death occurred at
<br />the lime. date and place and due 10 the cavsel&) stat8d.
<br />
<br />NO
<br />
<br />.b WAS CONSENT GRANTED'
<br />o YES ~ NO
<br />
<br />~~AND AQ.~ OF CERTIFIER IPHV~~,!, CORONER'S PHVSICIAN OR COUNTY A nORNEVI (Typo "'..!!:!'IJ
<br />
<br />Richard
<br />
<br />
<br />32b. DATE FilED BY REGISTRAR (Mo.. Day. Y',I
<br />
<br />FEB 3 1999
<br />;,
<br />
<br />32a. REGISTRAF:!
<br />
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