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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF WEALTH HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE -ARE 51CA D PARTMtIWT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOO .V eE Did ®S.
<br />DATE OF ISSUANCE
<br />DEC 09 2013
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201309751
<br />• 01 AS 7 d ATE i EGIS R,(1R
<br />•
<br />isrAtx
<br />D•,EPARTMENT OF HiL=ALrr1-1) ND
<br />tIU!' * IN' sERtIICES :
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT 4
<br />CERTIFICA OF DEATH Q� _�3 6
<br />HHS-61 11/03 (65061)
<br />1. DECEDENT'S•NAME (FIrs1, M(ddla. Last. Su1Nxi
<br />Richard Earl Anderson
<br />2. SEX
<br />•Male,
<br />3.DATEOF DEATH . (MO:. Day. Yr)
<br />March 1 • ' •
<br />4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />Golden, Colorado
<br />58. AGE•Last Birthday
<br />(Yrs.)
<br />67
<br />58. UNDER 1 YEAR 1 5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo.. Day. Yr.)
<br />November 30, 1938
<br />MOS.
<br />DAYS r HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />508 -48 -1134
<br />ea. PUICEOF DEATH
<br />HOSPITAI• OInpatient ( xi NurengHomelLTC OHospkeFac*ty
<br />Bb. FACILIT Y•NAME (11 n011natHe1i0n, gill street and number)
<br />Beverly Healthcare - Park Place
<br />6c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />0 EtilOutpaMnl 0 Decedent's Hums
<br />O 03 OOthulSPedlyt
<br />84. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE•STATE
<br />Nebraska
<br />98 COUNTY
<br />Hall
<br />9e. CITY OR TOWN
<br />?rand Island
<br />90. STREET AND NUMBER
<br />3107 W. 16th Str
<br />94. APT. NO
<br />91. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />62 YES Q NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 14 Married 0 Never Married
<br />MSwbtin(seperuee• OWid Qowed CI Unknown
<br />109. NAME OF SPOUSE (First. Middle. Last, SufIli) 11 wire, give maiden name.
<br />Donna Rayer
<br />11. FATHER•S•NAME (First. Middle, Last. Sunlit)
<br />Carl Anderson
<br />12. MOTHER'S -NAME (Fi Middls, • Maiden Surname)
<br />Edna Schlie
<br />:mica 13. EVER IN U.S. ARMED FORCES? Diva dates of :mica I yes.
<br />(Yea, no, or unit.) Yes Nov 56 -Nov 58
<br />14a. INFORMANTNAME
<br />Donna Anderson
<br />141. RELATIONSHIP TO DECEDENT
<br />wife
<br />16. METHOD OF DISPOSITION
<br />O Burial 0 a7naiio
<br />14 Cremation OEntombment
<br />0 Removal 0 Other (Specify)
<br />161.EMBAVAFJI.SIGNATU
<br />�I //JJA/ et
<br />169. UCENSE NO.
<br />1191
<br />16c. DATE (Mo., Day. Yr. )
<br />March 1, 2006
<br />( 60. CEMETERY. CIOf16ATORY OR OTHER). CITY / TOWN STATE
<br />Westlawn Memorial Park Grand Island Nebraska
<br />1 7L FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stale)
<br />Livingston - Sondermann Funeral Home, 601 N. WEbb Road, Grand Island, NE
<br />170. Zip Coda
<br />68803
<br />CAUSE OF DEATH (See Instructions and examples)
<br />16 PART 1 Enter the chile 01 events-diseases. Intyries, or complicalwns••Ihat directly caused 8N dealh. DO NOT emu Ierminel 1wn(0 such in cardiac arrant, APPROXIMATE INTERVAL
<br />I
<br />V. respiratory arrest, or v111UIC er fibrillation within' 'hewing the egolog 00 NOTABBREVIATE. Enler only cad/ OA a Una. Add addlional ilnes 0 necessary. 1
<br />y
<br />IMMEDIATE CAUSE onsallodealh
<br />imMEDIATECAUSE(FWI (81 .. Agmet91 Cat `rJ LENT► al Car 44ei^ /L1.J
<br />eweweadi6°n u
<br />temliGT9 DUE 1 aet10dealh
<br />Ine1.91)
<br />Saquan6a9y 1u condllons, N)
<br />arty,leadiagllVwaawU,led DUE TO, ORA9A CONSEQUENCE OF. r onsatledaath
<br />ennM e.
<br />EnIV tteUNDERLYNOCMISI
<br />pleweeriryury that lntisled (
<br />rwuM
<br />Ow n a in dN lh ) DUE TO.014AS A CONSEOUENCE OF: r enaat Oath
<br />10 Oa
<br />LAST
<br />(O1
<br />(8. PART II. OTHER SIGNIFICANT CONDITIONS•C0nOiliarts canhibulin9 to Ihe death bid not resulting In Ilea underlying cause given In PART L
<br />2. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />O YES NO
<br />20. IF FEMALE
<br />O Not pregnant whhin pass year
<br />O Pragnanlal time ofdeath
<br />O Not pregnant, but pregnant within 42 days of death
<br />O Nat pregnant, but pregnant 4108yate 1 year talons dealh
<br />, Q Unknown lt pregnant withinIndeaatyou
<br />21*10 . NEROFDEATH
<br />,rl nstnral O HomkNM
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide O CaUdtrot0edatarm'uied
<br />2111.IFTRANSPORTATIONINJURY
<br />0 Driver/Operator
<br />OPassenger
<br />0 Pedestrian
<br />❑ other (Specify)
<br />31o. WAS ANAUTOPSY MOANED?
<br />OYES NO
<br />210. WERE AUTOPSY FINDINGS AVAIABLE TO
<br />COMPLETECAMSE OF DEATH?
<br />0 YES ,►iN0
<br />site, ate. (Sway)
<br />22a. DATE OF INJURY (Mo.. Day, Yr.)
<br />2211. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY•At home, farm.
<br />Waal. factory, office Du *ding, construction
<br />220. INJURY AT WORK?
<br />Q YES ONO
<br />261. DESCRICE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY• STREET a NUMBER. APT. NO. QTY ?OWN SATE ZIPCODE
<br />E4
<br />s •
<br />€Q
<br />2 30.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 1, 2006
<br />11 l
<br />4 i
<br />}
<br />E7rr
<br />24a. DATE SIGNED (Mo.. Day. Y')
<br />246.70.1E OF DEATH
<br />m
<br />230. DATE IGNEg (Mo., Day. Yr.)
<br />' 3/3 /6q,
<br />23c.TW1EOF DEATH -
<br />5:55PM m
<br />24c. PRONOUNCED DEAD (Mo., Day. Yr.l
<br />2W. TIME PRONOUNCED DEAD
<br />m
<br />•e To IM bolt of my knowledge. tleatn occurred 01 the Ilene, mate and place $ 8 O 24e. On me balls of asamrnatran 1ndier imaatrgahon. in my opinion death ocGnred at
<br />E 64 and due to the cause's) st led. (Signature and Title ) • B lime. date and place end du the csuse(s) slated. (Sigma,rs and Title) •
<br />the e (0
<br />u
<br />25. DID TOBACCO USE CONTRIB TN?
<br />)(YES 0 NO 0 PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />K O YES NO
<br />.60. WAS CONSENT GRANTED?
<br />Nol Applicable 11261 IS NO 0 YES NO
<br />! X
<br />_.2 NAME. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OA COUNTY ATTORNEY) (Type orPrinl)
<br />?c(( I L' C ;,. 7 its Cu jjer C , .l 4/4- lofi_g
<br />F 11 26a.REGlSTRAR'SSIGNATURE
<br />.
<br />""" N. U? L
<br />Neb. DATE FILE DBY REGISTRAR (Mo., Day. Yr.)
<br />MAR 7 2006
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF WEALTH HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE -ARE 51CA D PARTMtIWT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITOO .V eE Did ®S.
<br />DATE OF ISSUANCE
<br />DEC 09 2013
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201309751
<br />• 01 AS 7 d ATE i EGIS R,(1R
<br />•
<br />isrAtx
<br />D•,EPARTMENT OF HiL=ALrr1-1) ND
<br />tIU!' * IN' sERtIICES :
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT 4
<br />CERTIFICA OF DEATH Q� _�3 6
<br />HHS-61 11/03 (65061)
<br />
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