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<br />STATE OF NEBRASKA 20080.0368
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH A.NlJof.lfiiJ.1JANcSE/1VlcES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAt;iiEGJJIifDSN.mJIVfTH,:
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI8fJ(:tt$~a'rloN,'WHtifflls
<br />
<br />:~::~::::::;TORY FOR V'TAL RECORDS. ~~l
<br />
<br />JAN 3 0 200? AS'$I$t.~t4tJ!1iJ:qif;i~i#?
<br />LINCOLN, NEBRASKA HEAL:Tfl Afi!D'fflJ~~RVICES
<br />SlATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FiNAticE~~suPP' . . ..
<br />CERTIFICATE OF DEATH ,~- - - 718__
<br />
<br />1. DECEDENT'S.NAME (Firsl,
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />SUlllx)
<br />
<br />2. SEX
<br />Female
<br />
<br />3. DATE OF DEATH (Mo" Day, Yr.)
<br />J,anuary 21, 2007
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />Martha Marie Hargens
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Sa. AGE.Last Blrlhday
<br />
<br />(Yrs.)
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5C. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />90
<br />
<br />September 5,1916
<br />
<br />8a. PLACE OF DEATH
<br />HOSPITAL: XJ Inpalienl
<br />
<br />~: 0 Nursing HomelLTC 0 Hospice Faclllly
<br />
<br />a:
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<br />..
<br />0;
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<br />
<br />506-}2-6684
<br />8b, FAC:L1TY-NAME (:r not InstitLltlon, givl? strE!el and number)
<br />
<br />U ER/outpatlenl
<br />
<br />o Dec~del'!t's Hom~
<br />
<br />St. Francis Medical Center
<br />2620 W. Faidley Avenue
<br />
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />o [Q'. 0 Olher(Specily) 81. rf~n"ie r18"is"J...<;:.~R'~'
<br />8d. COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />Grand Island 68802
<br />ga. RESIDENCE-STATE
<br />
<br />9b. COUNTY
<br />
<br />
<br />gl. ZIP CODE
<br />
<br />Hall
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />9g.INSIDE CITY LIMITS
<br />Ij YES 0 NO
<br />
<br />520 North Broadwell 68803
<br />... ",,,,,co,,'", "'''' "' ,,^'. 0 'om" 0 "'" ,""" r ""' oc '"""" I'" "'""". "" '"""II. .", ,.. ='"'" "~.
<br />
<br />o Married, bul separale~ llil Wldowe~ 0 Dlvolced 0 Unknown
<br />
<br />..-,'~- "~- .....---------..~ ~
<br />11. FATHER'S.NAME (Flrsl, Middle, Last, Sulllx) 12. MOTHER'$.NAME (Flrsl, Mi~dle,
<br />Soren Rasmussen Marie Staai
<br />
<br />Maiden Surname)
<br />
<br />14b RELATIONSHIP TO DECEDENT
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales of service if yes. 14a.INFORMANT-NAME
<br />(Yes, no, orunk.) No Janice Simmons
<br />15. METHOD OF DISPOSITION
<br />!ill Burial U Donallon
<br />
<br />16b. LICENSE NO.
<br />fr-{ '43
<br />
<br />Dau hter
<br />16c. DAlE (Mo., Day, Yr.)
<br />
<br />January 25, 2007
<br />
<br />STATE
<br />
<br />
<br />CITY I TOWN
<br />
<br />U cremation 0 Enlombmenl
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />U Removal 0 Olher (Speclfyl
<br />
<br />Grand Island
<br />
<br />NebraSka
<br />--.-..
<br />17b. Zip Code
<br />68803
<br />
<br />Grand Island City Cemetery
<br />17.. FUNERAL HOME NAME AND MAILING ADonESS (Slreel. City orTown, Slalel
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />
<br />CAUSE OF DEATH (See instructions and examl,t-es-)-
<br />
<br />18. PART I. Enler the chain 01 e~--dlseases, inJuries, or compllcalions--that dlrecliy caused the dealh. 00 NOT enler lermlnal even Is sucl1 as c.rdl.c anesl,
<br />respiratory anesl, orvenlrlcular librlllalion withoul showing Ihe ellology. DO NOT ABBREVIATE. Enleronly one cause on a line. Add addlllonallines If necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />I
<br />I
<br />
<br />: ~elIO death
<br />
<br />_~"~_y-~_
<br />
<br />onsello doalh
<br />
<br />IMMEDIATE CAUSE (Final
<br />dls..se or condltlolHeoulllng
<br />~ld.oll1)
<br />
<br />(0)
<br />
<br />cw-~
<br />
<br />DUE TO. on AS A CONSEOUENCE OF:
<br />
<br />. l1 rJ-
<br />onselto ~e.lh
<br />
<br />Sequ.ntl.liy lisl conditions, If (b) .' C' A-I::::::..
<br />any, leading to U,. eaus.II.I.d DUE TO~ OR AS A CONSEQUENCE OF;
<br />on linea.
<br />Enl.r Ul. UNDERLYING CAUSE
<br />(dl..... or Injury th.llnltlal.d (c)
<br />th. .v.nlor..ulllng Ind..Ul) --DUE TO, o'R AS A CONSEQUENCE OF:
<br />fAg[
<br />
<br />onselto death
<br />
<br />(d)
<br />
<br />lB. PART It. OTHEFl SIGNIFICANT CONDITIONS-Condillons conlrlbuling 10 Ih. dealh bul nol '.5ultlng in Ih. underlying cause giVen In PART I.
<br />
<br />-':WAS MEDICAL EXAMIN.n
<br />OR CORONER CONTACTEDO
<br />
<br />DYES rK'NO
<br />
<br />At1If~~)l~~~
<br />
<br />
<br />,~
<br />
<br />2.l<6.IFTRANSPORTATION INJURY fi" WAS AN AUTOPSY PERFORMED?
<br />( 0 Oliver/Opera lor
<br />o Y.S ~NO
<br />
<br />yc. IF FEMALE:
<br />IZl Nol pregnanl within pasl year
<br />o Pr8gnanl alllme 01 ~eall1
<br />U Nol pregnant, bul pregnant wl1i1in 42 days of dealt,
<br />o Nol pregnanl, bul pregnanl43 days 10 1 year before dealll
<br />o u':;~o;~ii p~~gnant ';Iiiiln (". past year _w_ -- -
<br />
<br />a:
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<br />u:
<br />~
<br />w
<br />u
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<br />'0
<br />..
<br />'..
<br />15..
<br />E
<br />o
<br />u
<br />..
<br />1I1
<br />r=.-~-~'
<br />
<br />o Passenger
<br />o Pedeslrian
<br />
<br />o AccidenlU Pending Invesllgalion
<br />o oulclde 0 Co"l~ nol be detennined
<br />
<br />Yd. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />-Q_\'~.Q.N.q.
<br />
<br />o Oll1er (SpeC1ly)
<br />
<br />_~,7'"~'~....=-"--
<br />
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />
<br />22b. TIME OF INJURY
<br />
<br />22c. PLACE OF INJURY-At homo, f.rm, slreel, faclory, olflce building, construction sile, etc. (SpecifYI
<br />
<br />m
<br />
<br />~---~~---_.~--'_.~._-~.
<br />
<br />22e. DESCRIBE HOW INJURY OCCUllRED
<br />
<br />22d.INJUny Af WORK?
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJUnY - STREET & NUMBER, APT. NO.
<br />
<br />CllYlTOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />
<br />Am
<br />
<br />z>-
<br /><(uJ
<br />>- Z
<br />..c~cc
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<br />E.'" >- Z
<br />00::....0
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<br />"'00
<br />{2.rr.u
<br />o ~
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<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DE;AfH
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On Ihe basis 01 examination .nd/orinvesllgallon, in my opinion death occurred al
<br />the lime, dale and place an~ du.lo Ihe causers) slated. (S'gn.ture an~ Tille) y
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />2Gb. WAS CONSENT GRANTED?
<br />Nol Applicable II 26a is NO 0 YES ~O
<br />
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<br />
<br />,AlE (,8 fS()3
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