|
<br />
<br />".
<br />
<br />
<br />~.
<br />..
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN.SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINALREG.flSiioitfijLE.?!4'ITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICSSIiC1"iON, 'VfHtCFUS
<br />
<br />:::::::::::;TORY FOR VlT20E080 6 it 80 k#1I ~e;i!-'~
<br />
<br />~R 1 3 2007 "",v-'fJllTAJI!!.liYJI"'P9R~ ~i
<br />LINCOLN, NEBRASKA H~~~' "si}
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAN~AN!;l~. . '"-'-22c1:'91
<br />CERTIFICATE OF DEATH .; ,H
<br />
<br />1.DECEDENT'S.NAME (Flrsl, Middle.
<br />
<br />Marshall Dean Christensen
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Lall,
<br />
<br />
<br />Sulllx)
<br />
<br />2. SEX
<br />Male
<br />
<br />Sa. AGE.La,t Blrthdsy
<br />(ns.)
<br />
<br />Dannevirke, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />507-34-6718
<br />
<br />Bb. FACllITY.NAME (II not InlUtutlon. glv~ Itre.t and number)
<br />
<br />79
<br />
<br />Ba.PlACE OF DEATH
<br />
<br />December 6, 1927
<br />
<br />~:
<br />
<br />o InpaUenl
<br />
<br />Qll:JEB: 0 NUIBlng HomellTC 0 HOlplce Faclllly
<br />
<br />o ERIOulpotlent
<br />
<br />iii Deoedent'. Home
<br />
<br />o
<br />~
<br />is
<br />;;i
<br />a::
<br />LU
<br />z
<br />[i!
<br />j
<br />'0
<br />
<br />I
<br />~
<br />dI
<br />~
<br />
<br />O[D/\
<br />
<br />o OlhOr(Speclly)
<br />Bd. COUNTY OF DEATH
<br />
<br />2107 N. Wheeler
<br />
<br />Be. CITY OR TOWN OF OEATH (Inoluda Zip Code)
<br />
<br />Grand Island 68801
<br />90. RESIOENCE.STATE
<br />
<br />llb. COUNTY
<br />
<br />
<br />Bg. INSIDE CITY LIMITS
<br />GiI YES 0 NO
<br />
<br />Hall
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />2107 N. Wheeler
<br />lOa. MARITAL STATUS AT TIME OF DEATH iii Married 0 Never Marned
<br />
<br />91. ZIP CODE
<br />
<br />68801
<br />
<br />10b. NAME OF SPOUSE (First. Middle, Lasl, SUIIIX) II wile, give molden nama.
<br />
<br />o Marned, bulseparoted 0 Widowed 0 DIvorced 0 Unknown
<br />
<br />Darlene Wells
<br />Sulllx) 12. MOTHER'S.NAME (Flrsl,
<br />
<br />Blanche Klien
<br />
<br />Middle.
<br />
<br />Malden Surname)
<br />
<br />Middle,
<br />
<br />Last,
<br />
<br />11. FATHER'S.NAME (Flrsl.
<br />Andrew Christensen
<br />,13, EVER IN U.S. ARMED FORCES? Give dalas of lelVlcellyas.
<br />(Yes, no. orunk.) Yes
<br />15. METHOD OF DISPOSITION 16a.
<br />IJl Bunal 0 Donallon
<br />
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />16c. DATE (Mo" Day, Yr. )
<br />
<br />Februa 26, 2007
<br />
<br />STATE
<br />
<br />o CremaUon 0 Entombment
<br />o Removal 0 Other (SpeCify)
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Coda
<br />68801
<br />
<br />Grand Island City Cemetery
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street. City orTown, Slale)
<br />All Faiths Funeral Home, 2929 $. Locust Street, Grand Island, Nebraska
<br />
<br />CAUSE
<br />
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />nstructlons and examp 88)
<br />
<br />f8. PART I. Enter the chain olavanla--dleeasos, Inlu~es. or compllcallons--that dlreclly caused lhe dealh. DO NOT enler lennlnal avents such as cardiac arr..~
<br />r..pl'.lory arr.a!. ",venlrlcular Ilh~lIallon without showing Ihe aUology. DO NOT ABBREVIATE. Enler only ona cau.e on a IIna. Add. addlbonalIInasIf naea.sary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />on.ello dealh
<br />
<br />IMMEDlATECAUSE(Fnel
<br />dll_ or condllonrewttlng
<br />Indtelh)
<br />
<br />(a)
<br />
<br />
<br />
<br />ON<. ..a
<br />
<br />'m"<""f
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on..llo daalh
<br />
<br />(J;::' Luv
<br />
<br />
<br />QS,-lOSIM Co
<br />DUE TO, OR AS A CONSeQUENCE OF:
<br />
<br />Sequenllally llalcondltlone, K '. (b)
<br />1IIIIi, Indlng \0 111. cllUllllelld
<br />on linea.
<br />Enter lit UNDERLYtlO CAUSE
<br />(dl..... or inJury lI1at Inltl.lod
<br />the tvenll ruullng In deall)
<br />IISJ'
<br />
<br />(e)
<br />
<br />on..tlo death
<br />
<br />DUE TO. OR AS A CONSeQUENCE OF:
<br />
<br />(d)
<br />
<br />lB. PART II. OTHER SIGNIFICANT CONDITIONS.Condlllonl cont~buUng 10 the daalh bul nol resulting In the unde~ylng causa given In PART I.
<br />
<br />19. WAS MEDICAL eXAMINER
<br />OR CORONER CONTACTED?
<br />o YES ~ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />
<br />C o/~
<br />
<br />a::
<br />LU
<br />y;
<br />~
<br />j
<br />!
<br />E
<br /><3
<br />.!
<br />{l
<br />
<br />21a. MANNER OF DEATH
<br />~ural 0 Homlclda
<br />
<br />.0 AccldanlO Pending In."Ugatlon
<br />
<br />o Suicide 0 Could not be delennlned
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />o D~verlOparator
<br />
<br />o Passenger
<br />
<br />o Pedesl11an
<br />
<br />o Olher (Sp.clly)
<br />
<br />21d. WERE AUTOPSYFINDINOS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />o YES ~O
<br />
<br />~O. IF FEMALE:
<br />o Nol pregnan( within pas I year
<br />o Pregnant at time of daalh
<br />o Not pragnant, bul pregnant within 42 days ot dealll
<br />o NOI.Praonant, but pregnanl43 days 10 1 yaarbelora dealh
<br />o Unknown If pregnant within the past yaar
<br />
<br />o YES
<br />
<br />J'tNO
<br />
<br />22a. DATE OF INJURY (Mo" Day; yr.)
<br />
<br />22b. TIME OF INJURY 22C. PLACE OF .INJURY.Mhome. larm, slraat, taclory,olnca.bulldlng.,conslrueUon site, etc. (Speclly)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />DYES 0 NO
<br />
<br />22a. DESCRIBE HOW INJURY OCCURRED
<br />
<br />22r.LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODe
<br />
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />Februar 22
<br />23b. DATE SIGNED (Mo., Day. Yr.)
<br />-d1
<br />
<br />24a. DATE SIONED (Mo., Day, Yr.)
<br />
<br />24b, TIME DF DEATH
<br />
<br />Hi
<br />...-z
<br />.I:I!,!g;
<br />l~~~
<br />E." t Z
<br />815510
<br />..z;;>
<br />.1:108
<br />a80
<br />
<br />rn
<br />
<br />23c. TIME OF DEATH
<br />2:00 P.rn
<br />
<br />24C. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On lIla basIS 01 axamlnoUon and/or Investigation, In my opinion death occurred al
<br />thalima, dale and plac, and dualo the cau..(s) stated. (Slgnatura and Tltla) "
<br />
<br />26a. HAS OROAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Nol Appllcablalf 261 Is NO 0 YES 0
<br />
<br />68803
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />28b. DATE FILED BY REOISTRAR (Mo., Day. Yr.)
<br />
<br />MAR 1 2007
<br />
<br />p
<br />
|