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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE R,4ISED SEAL OF THE N�BRASKA DEPARTMENT OF HEALTH„�q�il11Q�� SEI�VICES, IT CERTIF'IES
<br />TME BELOW TO BE A TRUE COPY OF TME pRIGINAL RECORD ON FILE WITM TH� NEBRA.ZR9A Q� ARTQIE ��1F H�}tLTH ANP
<br />HUMAN SERVIC�S, VITAL RECORpS OFFICE, WH7CM IS THE LEGAL p�P�SITOl2Y FOf��`17",4�E. �2�CQRC1,�.� � j r
<br />DATE DF ISSUANCE �
<br />�"� ��i
<br />� ' r
<br />06/07/2010 � 010 0 9 s 4 7 ���GEY S. COOPER ,'` �' �°�'
<br />i�5",$Y.�TAl1�'�T�R GISTfi�t� ;J
<br />DEPi1F�TMEl�T�O'F�H�,�TH /}M7 ;�
<br />LINCOLN, NEBRASKA FI,UM,41N SERVICE� •" ; ' �
<br />� . • �� "
<br />$TATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICB6 1 r �� �
<br />�r � � 4 �.•. x
<br />ncnY�r�nwT� �r ���T� � ����� �'.. �.�°' 10 01541
<br />v��� � n�v�� a.. vr YGMt fl ,� ... •
<br />1. bECEQENTS-NAME (Flrst, Middle, Lasy $uttlx) 2. SEX � , AT'�A D�qTN (Mo., Day, Yc)
<br />Orvllle William Herman Hanke Male �" '`` ', l�Ac�r�J; ��010
<br />4. CITY AN� STATE OR TERRITQRY, pR FOREIGN COUNTRY OF 61RTH 5a. AGE - Last 8lrthday 6. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., �ay, Yr.)
<br />(Y�•) Mp3. DAYS HOURS MINS.
<br />5tuttgart, Kansas 83 Janue 22, 1927
<br />7. SOCIAL $ECURITY NUMBER 8a. PLACE bF DEATH
<br />509-34-6979 HOSPITAL 0 InpatleM OTFIER � Nursinp Homa/LTC Q Ho�plce Faclllty
<br />Bb. FACILITY-NAME (If not Institutlon, glvp streat and numbar) � ER/Outpatlam ❑ Decedant'� Home
<br />K
<br />� Tiffany Square Care Center ❑ �oa [] Othar (Speclfy)
<br />� Bc. CIl"lf OR TOWN OF DEATH (Includa Zlp Code) 8d. CqUNTY OF DEATH
<br />a Grand Island 68803 Hall
<br />� 9�. RESIpENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Grand island
<br />�7 9d. 37REET qND NUMBER m. AP7. N0. 9f. ZIP CODE 9a. INSIDE CITY LIMITS
<br />� 2521 W.Anna fi$603 � YES ❑ No
<br />� 7aa. MARITAL STATUS AT TIME OF DEATH � MarrNd Q Naver Marrled 10b. NAME QF $POUSE (Firsq Mlddle, I..ast, Suttix) H wHa, plva maldan name
<br />!� � nnaRiea but separated ❑ wiaowea ❑ nwo�cen ❑ Unkrpwn Freda Dorinda Liggett
<br />� 17. FA7HER'S-NAME (Firet, Mmdla, Last, Sufflx) 72. MOTFIER'S•NAME (Flrst, Mlddie, Nlalden Surname)
<br />�, Oscar W Hanke Louise Mayer
<br />a ' 73. EV�R IN U.S. ARME� FORCES? Giva dates of servica M Yea. 14a. INFORMANT•NAME 746. REWTIONSWIP TO DECEI]ENT
<br />E
<br />s �vas, No, ar Unk.) Yes 09/27/1950-09/19/1952 Freda Hanke Wife
<br />� 15. METh10D OF �ISPOSITIpN 16a. HMBALMER�SIGNATIJRE 16h. LICENSE NO. 18c. DATE (Mo., Day, Yr.�
<br />F ❑ suha� ❑ oonaeon Not Embalmed
<br />June 2, 2010
<br />� Crematlon ❑ Entombmant 16d. GEMETERY, CREMATORY OR QTHER LOCATION CITY / TOWN STATE
<br />Q Ramoval 0 Othsr (SpacHy)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HpME NAME AND AAAILING AOpRE33 (Street, Cily or Tpwn, $tata) 17b. Zlp Code
<br />All Faiths Funeral Home, 2929 S. Lpcust Street, Grand Island, Nebraska 688p1
<br />F D se instru ons an exam es
<br />�e. Paar i. emar ene cnai� or o�o�t■-��seaaas, �n�unas, or compncanona-that dirocty cauwu tm ewm. op NOT smer tarmina� awna aucn aa cardiaa arceaL ; APpROXIM/ATE INTERVAL
<br />resptratory arron, O� Wntdcpla� fl6p11M1011 WkhOUt thOWinp thY itlolopy. �p NOT AB9REVIATE. E�r O�ly OM Ci11K Orl Y IInY. Add Yddll10�71 IIIIli N 116CB�Wry.
<br />IMM�DIATE CAUSE: ; orqet to death
<br />IMM[UTATE CAl1SE (Flnal a) Parkinsons Disease ; Several Years
<br />aiwaaa ar condn�on re�unlnp
<br />in dsath) DUE TO, pR A$ A CQNSEQUENCE OF:
<br />: onsatto death
<br />Sequsmisiry I�st conaitmn�, rc b)
<br />arry, leading to t11a CeuN Ilatad
<br />on Ilna a.
<br />DUE TO, OR AS A CON5�QUENC� OF: � arupt to daath
<br />ErItB� th0 UN�ERLYIN� CA�SE C'�
<br />(tllwYw or InJury that Initlated
<br />tha wem� roauttlny In dsathl pUE TQ OR AS A CONSEQUENCE OF: � Onsat to daath
<br />�nsr d)
<br />18. pART II.OTHER SIONIFICANT GQNDITIONS�Conditlons coMributing to the death buf not rosuRlny In tha underlylny cauRa given In PpRT I. 18. WAS MEDIGAL EXAMINER
<br />OR CORONER CONTACTED9
<br />y ❑ YES � NO
<br />W 0. IF FEMALE: 27a. MANNER QF pEATH �1b. IF TRAN5PORTATION INJUR Y1c. WAS AN AUTOP8Y PERFORMEp7
<br />� � Not prrynant wkhln pa�t yeA� � Natunl � HomlGda � �dvsdOpsrato�
<br />W Pnynant at tima ot caath � P � n � r ❑ YES � NO
<br />V ❑ � Mxld6nt � Prndln9 Imastly�tlon
<br />� No� propnant, but prapnam within ax daya of deatb Q Padendan 21d. WERE AU70PSY FINDIN(35 AVAILABLE
<br />�' Q SWclds � CoWtl no! 6� dHarmined TO CpMP��TE CAUSE OF DEA7N7
<br />� � Not prepnaM, bUt plBpr111�1t 13 Wy� ta 7 yaar 4eToro dl711h Q Othar (SpaclTy)
<br />� � UnknOWn If propniM w1t111n thr paat y�r ❑ YES � NO
<br />$ 22a. DATE OF INJIIRY Mo., Da Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, strea facto oTfice bulldl ( p Ify)
<br />$ ( Y� t, ry, np, constructlon slta, etc. S ec
<br />�' 2xd. INJURY AT WORK7 22p. p�SCR18E WOW INJURY OCCURRED
<br />O
<br />~ Q YE$ [] NO
<br />R2f. LOCATiUN OF INJUItY - STREET 6 NWM86R, APT.Np. GfTYITONfN STAT� ZIP COOE
<br />28a. DATE OF �E47H (Mo., Day, Yr.r' °--- -__ ->�� 24a. DATE SIGNED (MO., pay, Yr.) 24b. TIME pp dEqTN
<br />� � May 29, 2010 �
<br />�� y 23b. �A7E SIGNED (Mo., Day, Yr.) 2Sc. TIME pF OEATH ��} Yac. PRONOUNCED DEAO (MO., Pay, Yr.) 24d. TIME PRONOUNCEO DEAp
<br />� June 2 2010 04:3D AM �t �`�
<br />��z
<br />0 3d. To tha da�t of my knowlrtlqa, death occurrod at ihs tlma, AaW anA plap $� � py, q� py ppsla Of �xamlrwtlan andlor Inw�SlqaGon, In my opin�on Awth acwmd at
<br />B� and dU! �O tM GUM��) dand. (Slqnslun and Tkls) $�� thi t1'1p, tlih and plap and dU! t0 th! CaUtNi) �t0tid. (SlpnNun and Tkll)
<br />~ Donald Wirth, MD ~ � �
<br />2S. �ID Tp9ACC0 USE CONTRIBU7E TO THE DEqTN4 28s. HA$ ORGAIN OR T►SSUE DpNqTIGN BEEN CONSIDERED? 286. WAS CGNSENT fiRANTED?
<br />❑ YES � NO [] PROBABLY ❑ UNKNOWN � YES � NO Not Appllca6le H 28a Is NO ❑ YES ❑ NO
<br />• paor rn
<br />Donald Wirth, MD, 2116 W Faidley #400, 6ox 9802, Grand Island, Nebraska, 68$03
<br />28a. REGISTRAR'S SIGNATURE Reb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 4, 201D
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