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CADAS AO ~
ADAMS COUNTY, NE
FILED
INST. N0. ~ e~ ~ ~
Date ~ -~ - 0~ Timed
~~
REGIS7Ef3 Of= DEEDS
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY.OF THE ORIGINAL RECORD OIIFFlLE=WITH ,
THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTL_CS SEGT/ON~WNICH.IS `j (1 (~ ~ ~ `,
THE LEGAL DEPOSlTORYFOR VITAL RECORDS. - `- ` -- ~j {J ~J ~
DATE OF ISSUANCE ~ ~'
,~~NN '~+ q r~ r/~~~GnANLEY S. COOPER~_
IIIA~ .l. A LDOL. ASSISTANT STATE REG/STR:4R-
LINCOLN, NEBRASKA HEALTH AND HUMAN,SERVICES SYSTEIYI=
-- - -
STATE OF NEBRASKA- DEPARTMENT OF ! ~ALTH AND HUMAN SER\?FCES FINANCE xiND_S[IPPORT
VII'ALSTATISTICS _ __ _ rr,, fr11 nn p
CERTIFICATE OF DEATH - U 2 V `-t (.~ ~ J
~~~c~erv I rvnmt FIR$I MIDDLE LAST - 2. SE% 3 DATE OF DEATH rMOnrh. Da~,: Year!
George _ K. Hanson Male April 21, 2002
4. CITY qND STATE OF BIRTH 111 no( in US 9 name cnunlryl 6a AGE - Lasl Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /MOnlh. Dav Year)
Adams County, Nebraska IVrsl Sb MOS i DAYS
80 Sc. HOURS MIN$
February 22, 1922
7 SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH -
508-14-3784 HOSPITAL ^ Inpalienl OTHER ® Nursing HOme
8b FACILITY -Name /ll nor m5lrlulion. give 5lreel aM numbe// ^ ER Oulpatienl ^ Residence
Perkins Pavilion ^ DOA ^
OfherlSpec~lvr
8c f,ITV TOWN OR LOCATION OF DEATH Bd INSIDE CITV LIMITS Be COUNTY OF DEATH
Hastings Yes ^X Nd ^ Adams
9a RESIDENCE -STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER tlncluding Lp Codel 9e INSIDE CITV LIMITS
Nebraska Adams Hastin s 302 E. 6th Street, 68901 ~ Yes ® No ^
10. RACE - le.g., Whlle. Black. American Indian.
t
IS
l 11. ANCESTRY leg.. Italian. Mexican. German, elcl 12. ®MARRIEO ^ WIDOWED 13 NAME OF SPOUSE !I/ wAe. give maiden name).
e
oecl
yl
c I
White ISpecilVl
Swedish
NEVER DIVORCED
MARRI D
M rtle Fa a Booth
14a. USUAL OCCUPATION /G~ve kind o/ work done during moll
of working tile, even i/ rehredl 14b KIND OF BUSINESS INDUSTRY 16. EDUCATION ISpecily only highest grade completed)
Farmer Agriculture Elemep(~y or Secondary 1012) College U-4 0~ b l
U[,
I6. FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST
MIDDLE MAIDEN SURNAME
Oscar Hansor. Lenore Johnson
18. WAS DECEASED EVER IN U.S. ARMED FORCES? t9a. INFORMANT -NAME
IVes no. or unk.l III yes. give war arc! tlates of services)
~'o j Faye Hanson
79h. INFORMANT MAILING ADDRESS IST FlEET OR R.F D NO.. CITY OR TOWN. STATE. ZIP(
302 E. 6th, Hasti ,Nebraska G8901
ALM - N TURES CEN ENO. q
~~~ 21a METHOD OF DISPOSITION 21 b. DATE 21 c. CEMETERY OR CREMATORY NAME
~/ ®Bunal ^ Rempval 04/24/2002 Parkview Cemetery
2 F ER HOME ~ NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
Livingston-Butler-Vollaud Funeral Home ^ Cremaaon ^ Dnnalin~ Hastings, NE
22b FUNERAL H~JME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
1225 N. Elm Avc. Iastings, NE, 68901
23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR gal. Ib)
ANO Ic)I I I
t
l
.
n
erva
between onset and Aeall•.
PART )
I
gal wl ~GL.,;.~,,..v,:-,-~,,/%:
~ j DUE TO, OR AS A CONSEQUENCE F
I Interval between onset and death
I
~1/i~~
~
___
C-Ca ~
tr,~ G~2~, _ I
DUE TO. OR AS A CONSEOUENt~~ttOF J ~ I
nle~val between on~el ano dear
Icl i
OTHER SIGNIFICANT CONDITIONS ~ Cmdibons contributing to the death but not regaled
PART PART III IF FEMALE. WAS THERE A 2A AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
II J -
1
I PREGNANCY IN THE PAST 3 MONTHS? E%AMIN ER OR CORONER
~
^ GL~ )Ages 10-SAI Yes No Yes No Yes No
2Ba. ~ 26b DATE OF INJURY /MO. D;ry Yr) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
Accident ~ UndelunnmeU
M
Suicide ~ Pendinq 26e. INJURY AT WORK 261 PLACE OF INJURY - AI hone. tar m, sueel. lactory
oH~ce budding
etc lSpecilyJ 26g. LOCATION STREET OR R.F.D. NO. CIT'/ OR TOWN STATE
Homicide Inve5ligalinn .
Ves No
27a DATE OF DEATH lMn. D.rv Yr/ - 28a DATE SIGNED /Mo. Dav. v. i 26b TIME OF DEATH
a ~ 27b /n TE SIGNED (MO.. Day. » I 27c TIME OF DEATH ~ K' ~ 28c. PRONOUNCED DEAD IMO.. Oay. Ycl 28tl. PRONOUNCED DEAD /HOUrI
M ~ ~'-
M
- ,~ 27d Tn IItC best UI my knovrlndge. nealh Ocrnrred al the Ilme. dale and olaCe arld due In Ine _ ¢° ° 28e. On the basis of examination and o nvestigation, in my opinion death OCrurred al
causelsl staled. ~ ~ ° ~ the Ume, date and place and due b the causelsl staled.
!S~ nature and Tltlel ~ //~ left C(
(~ ~~
'
~ /L
~
,(.
~
~ ISM nature and Title) ~
'
29. DID TOBACCO USE CON
(f11BUTE TO TH 'DEATH? 30.a HAS ORGAN OR TISSUE. DONATION BEEN CONSIDERED 30.b WAS CONSENT GRANTED
^ YES ~ NO ^ UNKNOWN ^ YES ~ NO ^ VES ® NO
31. NAME AND ADDRESS Of- CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( !Type w Prrnll
Dr.Michael G. Skoch, 22 E. 14th St. Moscati, Hastings, Nebraska 68901
32a REGISTRAR 326. DATE FILED BY REGISTRAR /MO.. Day Yr.)
Scott Creek Subdivision, Adams County, Nebraska;;