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<br />.
<br />
<br />STATE OF NEBRASKA
<br />
<br />
<br />~HEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT QF HEAtm~tJ'b~~MI!N SERVICES, ITCERTlFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH THE NEItRA:j~A \i)~'pA~M~N~ OF HEAL TH AND
<br />
<br />HUMAN SE:~::F~~:~A~::RDS OFFICE, WHICH IS THE LEGAL OEPOS~~~~:4~~
<br />I, ,; jjr~NL~ ~COOPER ': ~;\', "
<br />200 8 0 92 4 9 :' t4~IS~ftj;4IEU~EG~Sl?J!.R
<br />" ''r:!ERARTMENT OF HEA~i.H~ND
<br />L-I-NCOLN, NEBRASKA ,',. Hpflft'Y:R,ERVlCE5, .,. .,: C'~i :~
<br />, ';-. ....1$'5.') , C,\_',' x."
<br />"I,' ("'.". ('1' '~'-' " ."~ I'.'"'
<br />STATE OF NEBRASKA - DTi~7TMENT OF H'DL TH AND HUMAN SERVIf~8': c', tG}.g~' . 2'8.53 0
<br />
<br />1. llECEllENT'S.NAIIE (Flret, Mlddlo, ...~ Sulllx) 2. SEX 'QffT,!t , TH (Mo.,tI.y,Yr.)
<br />
<br />Male Au ust 9, 2008
<br />a.. AGE'~GI Blrthdoy lb. UNllElll YEAR Ie. UNllER l11AY I. lIAT!! OF BIRTH (Moo, Coy, Yr,)
<br />
<br />SEP 2 4 2008
<br />
<br />Richard Dean Christensen
<br />
<br />.. CITY ANll ITATI! OR T1!RRlTORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />lYre.)
<br />
<br />MOS, DAYS
<br />
<br />HOURI MINS.
<br />
<br />Dannevirke, Nebraska
<br />1. SOCIAl.. SECURllY NUlIIBER
<br />
<br />80
<br />
<br />January 3, 1928
<br />
<br />508-3D-8039
<br />
<br />a.. P~CE OF llEATH
<br />'~ lApirtlont
<br />DE~
<br />DDOA
<br />
<br />lIT!:!I:B;, Il!I Nunllng HomeJ~ TC
<br />o ......... """-
<br />o Othot1Spoc/fy)
<br />
<br />o Hooplco Focill1y
<br />
<br />lib. FACIUTY_E (If not _, Ill'" 0_ one! number)
<br />
<br />---:- i'., --
<br />
<br />Wedgewood Care Center
<br />Ie. CITY OR TOWN OF llEATH (Includo ZIp Codo)
<br />Grand Island 68803
<br />Ie. RESIDENCE.STATE lb. COUNTY
<br />
<br />8<1. COUNTY OF DEATH
<br />
<br />11. FATHER'8-NAME (Flro~ Mlddlo, ~.t Sumxl
<br />
<br />
<br />81. ZiP CODE
<br />68803
<br />o Nover Moniod lOb. NAMI: OF SPOUSI: (F1ro~ Mlddlo, ~aot, Suffix) If wllo, give moldon n.......
<br />o Unknown
<br />
<br />
<br />&g. INSIDE CITY UMITS
<br />!l Y.. 0 No
<br />
<br />w
<br />z
<br />;:,
<br />...
<br />j
<br />~
<br />~
<br />i
<br />8
<br />~
<br />{:.
<br />
<br />Nebraska
<br />Id. STREET ANll NUMBeR
<br />4127 Manchester Road
<br />lOa. IllARlTA~ STATUS AT TIME OF llEATH iii MonIod
<br />o Momod, but ..po_ 0 Wldowod 0 Dlvore.d
<br />
<br />Hall
<br />
<br />Mlddlo, Molden Su""'mo)
<br />
<br />So hU$ B Christensen
<br />
<br />13, EVER IN U.S. ARMED FORCli'S? Give doteo oI..rvlco II Y..,
<br />
<br />(Y'., No, or Unk.) No
<br />
<br />16. METHOO OF DISPOSIOON
<br />00'.,,"1 OOono.o.
<br />OC.-oIlo. OEntomI>monl
<br />OR.mow.1 Oot""'l~
<br />
<br />Holt
<br />
<br />1..... RI!~TIONSHIP TO DECEDENT
<br />
<br />18<1. CEMETERY, CREMATORY OR OTHER ~OCATION
<br />
<br />ClTYITOWN
<br />
<br />Wife
<br />lie. llATE (Mo., CoY. Yr.)
<br />
<br />Au ust 13, 2008
<br />STATE
<br />
<br />lib. ~ICENSI! NO.
<br />139D
<br />
<br />Grand ISland City Cemetery Grand Island
<br />
<br />170, FUNERA~ HOMI! NAME ANll MAI~ING AllDRESS (Stroot, City or Town, Slolo)
<br />Jacobsen-Greenway Funeral Home, 4110 Street, PO Box 112, 51. Paul, Nebraska
<br />
<br />Nebraska
<br />17b. Zip Code
<br />68873
<br />
<br />
<br />lee
<br />
<br />IMMEDIATE CAUSE (Fino'
<br />dlooo.. Or condl~on .....IUng
<br />'n_)
<br />
<br />IMMeOIATE CAUSe:
<br />)..
<br />0) C~\O
<br />
<br />: APPROXIMATE INTERVAL
<br />
<br />!~tlO_
<br />
<br />,,/'1......... 0
<br />
<br />/J-r ri'-:F
<br />
<br />Soquontlolly lIot condition., If D)
<br />any, Isadlng to the CIU.. lI.led
<br />on IIn, o.
<br />
<br />llUE TO, OR AS A CONSEQU NCE OF:
<br />
<br />4r.
<br />
<br />: on..t to doath
<br />
<br />llue TO, OR AS A CONSEQUI:NCE OF:
<br />
<br />d)
<br />
<br /><i~.~,
<br />
<br />lono.llo deolh
<br />
<br />
<br />
<br />! oneot Ie do.'"
<br />
<br />Enter tho UNDERLYING CAUSE c)
<br />(cU..... or Injury lh8llnlUolod
<br />1110 o..nto ...ul~ng In "'oth) DUE TO, OR AS A CONSEOUI:NCE OF:
<br />~T
<br />
<br />P b,./{L-~ "5 II r-
<br />
<br />18. PART II. OTHER SIGNIFICANT CONllITIONS-CondIUon. conlrlbutlng to lho daolh but not rooultlng In lh. undorlylng COIU.. given In PART I.
<br />
<br />It:
<br />LU
<br />Ii:
<br />~
<br />w
<br />u
<br />j
<br />J
<br />
<br />g,
<br />~
<br />U
<br />
<br />5 IJ.....JL
<br />
<br />0->- ()~
<br />
<br />, AS MI!IlICAL EXAMINER
<br />OR CORONER CONTACTEll?
<br />o YES ~.
<br />
<br />20. IF FEMALE:
<br />o Not pregnant within plIBt yur
<br />o Prognont ot Umo 01 doolh
<br />o Not prognon\, but prognont within .2 do" 01 d.....
<br />o Not pregnont bul progn.nt 043 doyo 10 1 yoor bolo.. death
<br />o Unknown II prognont wllh'n Iho poot y,or
<br />
<br />na. ~NliR OF DEATH
<br />~lUurel 0 Homlcldo
<br />o Accldont 0 Pondlng 1n...Ugo~on
<br />o SuIcide 0 Could nol be dotonnlnod
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />o llIIverlOporotor
<br />o P....ngor
<br />o Pod_on
<br />o OIhor (SpocIIyl
<br />
<br />c. WAS AN AUTOPSY P~OIUlEll?
<br />DYES ~
<br />
<br />21<1. WERE AUTOPSY FINtIINGS AVAlI.A8~E
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES DNO
<br />
<br />22o.lIATI! OF INJURY (Mo.,lloy, Yr.)
<br />
<br />
<br />22b. TIME OF INJURY 22c, P~CE OF INJURY-AI homo, farm, .1roOt, loclory, oIIIco building, con.lruCllon olio, ole, (Specify)
<br />
<br />{:.
<br />
<br />ZZlttN.jIl_'
<br />DYES DNO
<br />
<br />221. ~OCATlON OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATI!
<br />
<br />ZIP CODI:
<br />
<br />
<br />. DATE OF llEATH (Mo., Doy, Yr.)
<br />
<br />3-Q-09.
<br />
<br />:Mol. lIATI: SIGNED (Mo., Coy, Yr.)
<br />
<br />2<81. TIME OF DEATH
<br />
<br />- I> - O~
<br />
<br />~~i
<br />II ilia
<br />llt:>
<br />5~o(!
<br />uw~
<br />~8
<br />rr:u
<br />815
<br />
<br />m
<br />
<br />b. lIATI! 8IGNED (Mo.. Coy, Yr.)
<br />
<br />24c. PRONOUNCED DEAll (Mo., Coy, Yr.) 24<1. TIME PRONOUNCED llEAll
<br />
<br />m
<br />
<br />:Mol. On 1110 boolo oIoumlnotion ond/or In...~gotion, In my opinion d_ occurred
<br />011110 ~mo, date ond ploco ond duo to tho couoe(.) 0_. (8IgnlUu.. ond TlUo)
<br />
<br />b. WAS CONSENT GRANTl:D?
<br />Not AppllcOblolf 260 10 NO 0 YES [3-ml'
<br />
<br />
<br />d13luAc/' I.J E " 8 g ()'
<br />
<br />28b. DATE FI~Ell BY REGISTRAR (Moo, Doy, Yr.)
<br />
<br />AUG 2 1 2008
<br />
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