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<br /> R�v.t t�97 STATE OF NF9RASKA•D�AICIMEN'f OF�ff 11LTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br /> VIfAL 31'ATISTICS
<br /> CERTIFICATE OF DEATH -• 1(.j�iaj�S
<br /> 1.pECEDENT•NAME FIRST MIODLE LAST 2.SE% 3.OATE OF DEATH /Mnrrm,piy,yqg �` �
<br /> Leola Gayle Hansen Female Marc6 06, 1998 �
<br /> 1.CITY AND STAiE OF BIRTH /pnpl h 1/S.A.�Nrrw NYNy) Sa AOE-WI BiNM�y UNDER 1 VEAR UNOER i DAV E.DATE OF BIRTH IMOntlt Osy YeN/
<br /> �Vn.l 50.MOS. DAVS SC.MOUFS' MINS.
<br /> Gre o ,South Dakota 77 � November 03, 1920
<br /> 7.SOCIAL SECURTn NUMBER !a PUCE OF DEATM
<br /> � 479-1&4088 �T� ❑ ��a� on±ea QX NwsirgFbms
<br /> Op.FACIUTY.WtM /NnOfwr�lifuqd�,yrol,fM/IJMM�n6N) � EROuiWNM ❑ R�siAenes
<br /> . St.Francis Memorial Health Center ❑ �� ❑ o�»��s,��w�
<br /> !C.CITY,TOWN OR IOCATION OF DEATM !0.INSIDE CRY UMITS Bs.COUNTV OF DEATH
<br /> Grand Island v�. �X r�w ❑ Hall
<br /> 9a RESIOENCE-STATE 9b.COUNTY 9e.CfTV.TONM OR IOCATIpN pd.STREET AND NUMBER //uNping Zip Codel 9s.INSIDE CITV LIMITS
<br /> Nebraska Hall Grand Island 209 East 21 Street,68801 ,.,,� N,�
<br /> 10.AACE-(�.¢,NRiiN.B1ack.Amsr��n Indan. 11.ANCESTRV p.9..11Y4^•ANme�n•(i�rm�n,Nel 12.❑MARRIED �WIDpWEO 1�.NAME OF SPOUSE lll xaM g�w m�idsn nemsl
<br /> ' etc.IlSosaNl ly
<br /> � White �n +ish/German NEVER OIVORCED Harry Oscar Hansen
<br /> 0 1N.USUALOCCUPATION IGrvekinddMCrkdon�dri�pmcsf t�b.KINOOPBU&NESSINDUSTRV 15.EDUCATION (Spec�yorNyhgMSlg�etlecomplstetl)
<br /> O d rwkrng InY.svsn il refirsdl
<br /> U Ebme i or SeconEary 10-�21 Cotbge It�a or 5•i
<br /> ,, Dentsl Assistant Dentistr ��
<br /> C tE.fATHER-NAME FIRST MIDDIE LAST 17.MOTHER FIRST MIDOLE MAIDEN SURNAME
<br /> 7
<br /> � - Maurice Horton � Olive Beatrice Moore
<br /> O • 18.WAS DECEASEO EVER IN U.S.MMED FORCE54 19�.INFOqMANT•NAME
<br /> � IYM.�+o.d unk.) IN yy.g�w w�r�nC dllst ol MnkM)
<br /> `- No Donna Van DeMark
<br /> � 19p.INFORMANT MAILINp AODRESS ISTREET OR R.F.D.NO.,CITY OFl TOWN.STATE.ZIP�
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<br /> °' 209 East 21Street,Grand Island,Nebraska 68801
<br /> V 20.EMBALMER-SIGNATURE d LICENSE NO. 21e.METIqppF pSpp$ITION Ztb.DATE 21c CEMETERV OR CREMnTOPY�NAME
<br /> WE � ���� ❑e�w ❑A«,a�.� 03/06/1998 Central NE Cremation Service
<br /> Q C 42a.FUNERAL MOME-NAME 2t0.CEMETERY OR CREMATORV LOCATION CI7V OR TOWN STATE
<br /> V � A�fel-Butler-Geddes Funeral Home ��� ❑��� Gibbon,Nebraska
<br /> W j, 22p.FUNERAI MOME ADDRESS (STREET OR q.F.O.NO..CITV OR TOWN,STATE,ZIP)
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<br /> O � 1123 West Second Grand Island,Nebraska,68801-5899
<br /> W � 23.PAqT IMMEDUTE CAUSE (ENTER ONLY ONE CAUSE PER IINE FOR ial.(bl.ANO�ep � Interval Delween onsel anr.oeau�
<br /> Q = ' (%kNC s� Q G�s� � � v.t s
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<br /> Z LL �1E TO.OR AS A CONSEOUENCE OF � Intsrval Oaiwssn onas�anC aeain
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<br /> DUE T0.OR AS A CONSEWENCE OF� I imervai Osiwaan orrosi and Ceam
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<br /> OTHER SIGNIFICANI CONOITIONS- wntibUGg to IM O�aM Ou1 rql rN�1s0 ppRT III IF FEMAIE.WAS THERE A 2� AVTOPSV I 25.WAS CASE REFERqED 70 MEDICAI
<br /> PART
<br /> n r �'� PREGNANCV IN THE PAST 3 MONTHS� EXAMINER OR CORONER
<br /> CN�tAN Ic.. � .S S I�s 10.5�1 Ya No Vn No Yss No
<br /> �+. 2lD.DATE OF IWURV /Ma.ay.rr� 28t.MOUR OF INJURV 2ld.pE$CqIgE MpW IWURV OCCURpED
<br /> � AcCdsnl � UMSIMminM
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<br /> ❑ �+'�� ❑ Pa�^9 28e.MJUNY AT WpqN � 281.PLACEp�INJNUeRY�N hp1p,lum,WN1,I�Cbry 28q,�pCAT10N STPEET OR R.f.D.NO. CITV OR TOWN STATE
<br /> ❑ ❑ � anc bui0iip spre�rl
<br /> Mom�c�d �nv�nnqatron Yn No
<br /> 27s.DATE OF DEATH /MO.pay.vc/ 2Ba.DATE SIGNED �hb..Day.vrl 2BC.TIME OF DEATH
<br /> � a /Y�'�(Cbt �i l S s �t�
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<br /> 27D.DATE SKiNED /Ah.D�y vc) c.TUAE OF DEATM ���T 29e.PFpNpUNCED DEAD /Ab..Diy,Yr.l 2Ed PRONOUNCED DEAD /Hqn�
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<br /> � � 27C.To tlM Dl71 d my k d��lOCCCP^^� � • !YM dW W tlM �° a 281.On iM DYU d OxWnx�dba�in0�W mMttyJatqn�in my OqnWn 0lelh OCCUrtOC!t
<br /> ew�Nsl aw�a. a Mis um�,aw and pl�cs uW aus oo iM uu�elsl anno.
<br /> � n+lur.,nd rme . ene na.
<br /> 2Y.qD TOBACCO USE CONTRIBUTE TO TNE pEI1T119 3p.a HA$OROAN OR TISSUE OONATpN BEEN CON&DERED? 30.0 WAS CONSENT GRANTED?
<br /> � YES � NO � UNKNOWN � YES � NO � VES � NO
<br /> 31.NAME ANO ADDRESS OF CERTIFIER�PHVSICUN,COfipNER'S PMVSICNN OR COUN7Y ATTORNEV� /T ����
<br /> ypI Cr P/n7/
<br /> Dr.David R.Colan,729 N Custer,Grand Island,Nebraska 68803
<br /> J2a.tiEGISTRAR 32p.DATE FILED BV REGISTRAR /A1p.,pgy,y��
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<br /> FOR VITAL STATISTICS USE ONLY
<br /> Place.......................A................................B................................C................................D................................E................................Part II......................TMV...........................
<br /> NSC...................................................................................................................................................................................................................................................Census Tract No.
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<br /> UC.............................................._..........................................................................................................................................................................................................
<br /> Reject..................................................................................................................................................................................................................................................
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