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<br />STATE OF NEBRA$Kd,, � � ` � �"�, �,�
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<br />I WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTM�NT �tF�A�T(��A� �dl�Nj�ttll� ,S�RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAt RECORD ON FIL�, VI/,iT'�-I',fiH�=��� � - A �� d�����`� �� ���TH AND
<br />, HUMAN SERVICES, VITAt RECORDS OFFICE, WHICH IS THE LEGAL DEPO$T1`Ol,�1' �R V,�'1',Ak ���7 !� p
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<br />DAi'E OF ISSUANCE �° t�.,��.��Q��
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<br />2 0�. 2 0 0 2 7 i �� �:�,��5 CO,OpER 1�., � X �
<br />12/13/2011 ' ~ a'ss�r���a►�',� R��'�S�ur�
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<br />+ �� DEPi�4RTM� .N' �' �F HF.�4l��'�I�AI�fD `
<br />LlNCOLN, NEBRASKA � �� '�,H411�1A ��R�l� � c':� ,o � �. �''
<br />L. � �� G � �t C y �..' � rr `�� a 3 ,� :'. .
<br />STATE OF N�BRASKA - DEPARTAAENT OF HEALTH AND HU� S�� `b� � a�o � � ,Nr
<br />CERTIFICATE OF DEATH ' t .� �, ,�. � . ,, t`;` � : �;���.� "�'F �^�`` , 11 04073
<br />1� DECEDENTS•NAME (Firet, Middle, Last, Suftlu) ' ' 2. Sbt; �� �, ,DATB OF DEATH (Mo., DaY. Yr.)
<br />° Shirley Marie Mderson Fema�e `''�`�� December 6, 2041
<br />4, C17Y AND STATE OR TERRITORY, OR FOREIQN COUNTRY OF BIRTH Sa. AGE - Last Blrthday . UNDER 1 YEAR Sc. UNDER 1 DAY. ; 8: DATE OF BIRTFi (Mo., Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS dUN3.
<br />° Denver, Colorado 82 February 25, 1929
<br />7: SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />� 508-2&3138 I s�r� ❑ im�tie+�t o THER Q Nuretr�g Homan.rc p Hoap�ce Facnny
<br />8b. FACILITY-NAME (If not InsUtutton, plve street and number) ��yp��M � Dm�daM's Home
<br />a
<br />� Tiffany Square Care Center ' ❑ ooA ❑ o�er lsaecKr?
<br />� 8c. CITY OR TOYVN OF D�ATH (i�xlude Zip Code) Sd. COUNTY OF DEATH
<br />6 Grand Island 68803 Hall
<br />� 8a, RESIDENCESTATE eb. COUNTY 9C. CITY OR TOWN.
<br />Nebraska Hall Grand Island
<br />� 8b.9TREET AQID NUMBER Be.APT. NO. 9L ZIP CODE 9g. INSIDE CITY LIMITS
<br />� 333 Pheasant Drtve � 68801 � vES ❑ No
<br />. 1U8. NIARITAL STATUS AT TIMS OF DEATH � Marrled �, Never Marrled ' 10b. NAME OF 9POU5E (Flrst, Middle, La8t, SuiPoc) If wffe, ghe malden �me
<br />� � nn�m�, b�n se��e�a p wia�aa p owor�a p u�� Jerry Anderson
<br />� 11: FATHER'S•NAME (FUst, Middle; Last, Suffl�) 72. MOTHER'S-NAME (First, Mlddle, M�Iden Sumame)
<br />Gamett Phi�er Opal Haskins
<br />, E, 13; E1/�R IN U.$. ARME� FORC�S? Ofve dates oi serviCe R Yqs. 14a. INFORMqNT•NAMB 14b. RELATIONSMP TO DECEDENT
<br />$ ; �rae, No, or ur�.� IUo Jerry 'Anderson Husband
<br />;$ 15. METHOD OF DISPOSITION 18a. EMBALMEIi�St(iNATURE ' 16b. LICENSE NO. 18c. �ATE (AAo., Day, Yr.)
<br />�, 0 Burlal ❑ Do�don i y
<br />Matthew T. M ers 1411 December 10, 2011
<br />� Crart�Uon ❑ E�ombmerR 18d. CEMETERY, CRENWTORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ eemova� ❑ Other (Specffy) �ntral Nebraska Crematlon Senrices Glbbon Nebraska
<br />17e. FUNBRpL HOME' NAME AND NWILINO ADDRESS (Street, Cily or Town, State) 17b. 21p Code
<br />All �aiths Funerat Home, 2928 S. Locust $treet, Grand Island, Nebraska 68801
<br />� ta PaFii 1. Enter the cha�n m evem�4laeases. Iryuries. or compacado�that dt�tlY cauaed tlre death. DO NoT e�rter terminal eveAte eurd� aa cartllac artest, . .
<br />'�, �c�Y ertasf, or veiWiwfar flbrIDation widfout e�!ortn9 �e edology. DO NOT ABBItEV1ATE EMaz oniy o�re causa on a Me: AAd addlUanal Mea If �ry.
<br />in�nuieuwrE cause:
<br />�eeee�owre cnuse � a) Breast Canc�r, Metastatic (Malignant Ascltes Md Pleural Effusiqn)
<br />eeE
<br />diseaee or eam�lon resulu�
<br />�°�� DUE TO, OR AS A CONSEQUENCE OF:
<br />�m�nr �s �o�awo�a N b) RecuRent Breast Cancer
<br />enr� i�ame eo ure eaa� n�a
<br />on Wre a' DUE 70, OR AS A CONSEQUENCE �F:
<br />enmr e�re ur�n�mrca cause ��
<br />(qlaease m tnJury that Inidatetl ' � �
<br />�evema memu� In deam► DUE TO, OR AB A CONSEQUENCE OF:
<br />d)
<br />nrPROwn�wre in�vau.
<br />o�et to death
<br />1 Year
<br />Initlal 1998
<br />o�et W death
<br />18� PART II.OTHER SIGNIFICANT CONDITIONS�Condidons eontrlbuting to the death but not reaulUng In the urMehying cause ghren In PART i. 18. WAB MEDICAL EXAMINER
<br />Cardiomyopathy (nonischemlc), GERp, Vftamin D Deftclency, Hypertenslon, Asthma OR CORONER CoNTACTED4
<br />� ❑ YES Q NO
<br />LL 0; IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMEDT
<br />� � Not P��t MIWn I�Y� �� NaWwi � HomiWde � D�(Ope�atm
<br />U � arepna�rt at Nrne oT death . O�� ❑�� �� � p��� � ❑ YES � NO
<br />� �] Moc pre¢nam, mn prepnane rmun aa aaye m a�d g�dde Couta �ros be de�t�red ❑ redeadl�, z7d. wERE AU70P5Y FlNDINGS AvARA
<br />Q Not P�e9�errt. but Wee� 49 daye m t Year betore death �, � � pq� (Bp�yJ TO COMPLETE CAUSE OF DEATH7
<br />� Ij� Unkrtown N P�eB�eM wnh�n Ure. Paet Year � . � - � . . _. � ❑. YES ❑ NO
<br />E 22�. DATE OF INJyRY (Mo:, Day, Yr.) 22b. TIME OR (NJURY 22c. PLACE OF INJURY•At home, farin, S6�t, factory, oftice buUding, corretruedon eke, etc. (Sp�tfy)
<br />s
<br />� 22d. INJURY AT WORK? 22e. DF.SCRIBE HOW INJURY OCCURRED
<br />1�-
<br />❑ ves ❑ No
<br />22►. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITYITONIN STATE ZIP CODE
<br />� ' 23a. DATE OF pEATH (Mo., Day, Yr.� . 24a. DATE SIGNED (Mo„ I�ay, Yr.) 24b. TIME OF DEATH
<br />.� Decem6er 6, 2011 ,�
<br />! 2Sb. DATE SItiNED (Mo, Day, Yr.) 23c: TIME qF DEATH �� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIINE PRONOUNCED DEAD
<br />�� Z December 8, 2011 01:02 PM <�
<br />�� � To t6e beat of mY ImowletlBe. death oewrtetl �the LLm. dale end Wace � � 24e. On Lre I�IS of mrmNnstlon endlm Imead9atlo�. in mY uWNon d�th oaurted at
<br />�',�-� aml due to ihe catme(e) steted. (8�gnature and'riN9) , $�$ tlm tim�. date 6nd Place Bnd due to tlte cause(s) s�. (Sl9nature and Tftle)
<br />� Kimberly A. Mickels, MD ~ g s
<br />, 2S pID TOBACCO USE CONTRIBUTE TO THE DEATH7 28a. HAS OROAN OR TISSUE DONATIOW BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />�❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES , � NO NotAppiicable H28a Ie NO ❑ YE9 ❑ NO
<br />2. AN P , 1 , ype or Prl
<br />j Kimbe�ly A Micdcels, MD, 729 North Custer Ave�lue, Grand Island, Nebraska, 68803
<br />� 28b. DATE FlLED BY REG .�I
<br />December 9, 2011
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