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STATE OF NEBRASKA
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<br />WMEN TMIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF MEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASIEA ~~~,,pA121rMC'~IVT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI~'~IZ',RE~al~1~, .
<br />DATE OF ISSUANCE ~~~~ ~, ;
<br />.. STANLEY S: -COf7PER ,
<br />OC7 2 1 2008 z o i o 0 7 1 9 4 ~' ,J.~SSIS~yNT~STATCs,.~4EGI5`~R,4R
<br />' DEpAR~C(r/T ~ 1~'E,ALTH ~D
<br />LINCOLN, NEBRASKAk~UA1AN SERVICES .-~ ;'~~ .
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<br />STATE OF NEBRASKA -DEPARTMENT OF MEALTH AND HUMAN 9FR~it~Sr~`~. [~ ~ ~= `~~ (y ~ ~.p
<br />CERTIFICATE= OF DEATH I.,! Q
<br /> t, pECEDENT'$-NAME (Flrot, Mlddle, Last, StiRlx) 2. SEX ~~ _ F, DEATjt o.,Dey,Yc)
<br /> Hans Ervin Sorensen Male October' 11, 2008
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OP BIRTH 8e. AGE-Leaf Birthdry bb, tlNDER 1 YFJ1R 8c. UNDER t DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yn.) Mp$, PAYS HDQRS MIN&
<br /> Cambridge, Nebraska 94 March 21, 1914
<br /> 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br /> 506-26-9557 HOSPITAL: ^ Inpadam OTHER: ®Nuninq Nome/LTC ^ Hospice Facility
<br /> Bb. FACILITY-NAME pf net Institution, qiw street end number) ^ ER/Outpadsnt ^ Decadence Homo
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<br />Park Place-A Golden Living Center ^ DpA ^ Other(Speclry)
<br />-I 8c. CITY OR TOWN OF DEATH preclude Zip Coda) 8d. COUNTY OF pEATH
<br /> Grand Island 68803 Hall
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<br />7 9e. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TpWN
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<br />~, Nebraska Hall Grand Island
<br />~ 8d. STREET AND NUMBER Ba. APT. NO. W. ZIP CDDE 9g. INSIDE CITY LIMITS
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<br />3990 W. Capital Ava.
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<br />B8803
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<br /> 70s. MARITAL STATUS AT TIME pF DEATH ®Married ^ Nwer Martiad 786. NAME OF SPOUSE (Pint, Middle, Last, Suffix) H wife, plus maiden name.
<br /> ^ Married, 6u! eapanMd ^ Widowed ^ Dlvvrced ^ Unknown
<br />~ Irene Marie Nelson
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<br />17. FATHER'8•NAME (Pint, Mlddle, Last, StdRx)
<br />12. MOTHER'S-NAME (Pint, Mlddle, Malden $umame)
<br />~ John Sorensen Matto Anderson
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<br />73. EVER IN U.$. ARMEp FpRCES7 Glvs dates of aarWce IT Yea.
<br />14a. INFORMANT-NAME
<br />14b. RELATIONSHIP Tp DECEpENT
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<br />(Yes, Nv, or Unk.) Np
<br />Irene Marie Sorensen
<br />Wife
<br /> tb. METHOD OF DISPOSITION 18 . MERSI U
<br />, 78b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br /> ®Bedal ^°°"""°" ~ ~~ .l ~ ~ ~ October 14, 2008
<br /> ^Cmmetlon ^Eneombmenl
<br /> ^lumoval ^wneryapsmry) 78d, CEMETERY, CREMATORY OR OTHER LDCATION CITYlTOWN STATE
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 77a. FUNERAL HDME NAME AND MAILIND ADDRESS ($troaf, Giry or Town, State) 776, 21p Coda
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSES OF DEATH See instructions and exam les
<br /> 7a. PART 1. Ennr d,e cn.e, nnvnr, - plaww", injenu, qr complk"tlon"-that dlncely caueap m" Audi. DD NOT emer temlMU ewme sacra a cardiac erre.q APPROXIMATE INTERVAL
<br /> naplratvry amr6 qr wmrkuMr a6dlNdgn without "howlne rlra alolvey. BO NOT ABBREVIATE. ErINr only om oawa an ^ IIM. Adp appafonal litres d Mnaaery.
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<br />IMMI:pIATE CAUSE (Final ` ``- `~ ~ ~ c ~1 ~,~'~ ~`~ I ~ I~ r
<br />disease yr condition resulting a) ~~' v `\ ~ (.r ~Qi(~~ •1 ~V V ~~()~~~ ~^" Y~~ ~• ~~~`~~~ I ~"" ~ I i,t
<br /> In death)
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<br />DUE Tp, OR AS A CONSEQUENCE QF: ~--~,~ I,r onset t0
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<br /> any, leading tv the cause listed
<br /> on Ilne a, DUE TO, OR AS A CONSEQUENCE OF: onset to death
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<br />Enter the UNDERLYING CAUSE c) I
<br /> (disease or Injury that initiated
<br /> the events resulting in death) DUE TO, OR pS A CONSEQUENCE OF: onset to death
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<br />n In PART I. 7B. WAS MEDICAL EXAMINER
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<br />(~ 27a. MANNER OF DEATH 21 b. IF TRAN$PDRTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />~ ^ Not prognant within peat year I' ` Natural ^ Homicide Q Ddver/Operator ^ YE$ ~NO
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<br />W ^prognant at time of death ^ Accident ^ Parading Inveatlgetlon ^ Paeeenger
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<br />^ Nat pregnant, but pregnant within 42 days of death
<br />^ Suicide ^ Could not be determined
<br />^ PedeaWan 27 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE DF pEATH7
<br /> ^ Na! pngnerd, but pregnant 43 days to 7 year 6efon duth ^ Ofhar ($paciry) ^ YE8 ^ NO
<br /> ^Unknown iF pregnant within the peat year
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<br />22e. DATE OF INJURY (M
<br />,Day, Yr.)
<br />226. TIME OF INJURY
<br />22c. PLACE OF INJURY-At home, farm, etroal, Tacldry, vTNce 6ullding, cdnalrucllvn ails, elc. ($paclry)
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<br />O 22d. INJURY AT WORKT 22a. DESCRIBE HOW INJURY OCCURRED
<br />~ ^ YE9 ^ NO
<br /> 22f. LDCAriON OF INJURY -STREET ti NUMBER, APT. Np. CI7YITDWN STATE ZIP CODE
<br /> 23a, PATE OF DEATH (Mo„ Day, YrJ 24a. DATE SIGNED (Mv., Day, Yr.) 24b. TIME OF DEATH
<br /> ~~ October 11, 2008 ~ ~
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<br />TIME OF pEATH
<br />PATE SIGNED
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<br />PRONOUNCED DEAD
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<br />TIME PRONOUNCED DEAD
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<br />j 2ae. pre the basis vT examination andlvr Inveetlgetlon, In my epinlon death occutnd
<br /> an e(a ($1 elan and Title) ,~ ~ V al the rims, date and plats and due m the cause(s) slated, ($Ignaturo and Title)
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<br /> 25. Dlp TpBAGGO U$E CONTRIBUTE TO THE OEATH7 28e. HAS ORGAN OR TISSUE DONATION BEEN CDN$IDERED7 28b. WAS CONSENT GRANTED?
<br /> ^ YES ~NO ^ PROBABLY ^ UNKNOWN ^ YES NO Nvt Applicable H 26a Is NO ^ YES NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHY$ICU1N pR COUNTY ATTORNEY) (Type dr Pdn!)
<br /> Steven Husen, M.D., 2116 W. Faidley Ave•:, Grand Island
<br />NE 68803
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<br />p 2Ba. REGISTRAR'S SIGNATURE ~
<br />~ 28b. DATE FILED BY REGISTRAR (Mo., Dey, Yr.)
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