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WHEN THIS COPY CARRIES TFE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTE14 R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RED TH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTL S THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 200004026 J 6000 M_ ON 91999 ASSINT$& LINCOLN, NEBRASKA HEALTH AND h MAN S SY )4 STATE OF NEBRASKA - DEPARTMENT OFH-X3EAL BUREAU OF VITAL STATISTICS CERTIFICATE OF DEATH I. DECEDENT -NAME FIRST MIDDLE LAST 2, SEX A I E OF DEATH /Month Day. Yearl Lois Louise Anderson Female May 31, 1999 4. CRY AND STATE OF BIRTH /enot n USA.. name country) 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Monlyi. Day Year] Mos. DAYS 5c. HOURS! MINS. IY'71 5b York Nebraska l June 2, 1927 7. SOCIAL SECURTIY NUMBER Be. PLACE OF DEATH 508 -22 -1154 HOSPITAL: Fx� Inpatient OTHER ❑ NursmgHome ❑ ER Outpatient ❑ Residence Bb. FACILITY - Name (M not msldu(on- give street and numberl . Box Butte General Hospital ❑ DOA ❑ Other(SpecAyi Sc CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS Se. COUNTY OF DEATH Alliance Yes ❑ No ® Box Butte ga. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /InclWing Zip Coapl 9e. INSIDE CITY LIMITS Nebraska Box Butte Alliance 1033 Sheridan Yes ❑X No ❑ 10. RACE - (e.g., While. Black. American Indian, 11. ANCESTRY leg.. Kahan. Mexican, German, etc/ 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE ld wile. give maiden name/ s�c�yl German I NEVER DIVORCED MARRIED Harold M. Anderson 14a. USUAL OCCUPATION (Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION ISpecdy only highest grade C(Xn dl Elementary or Secondary 10 -121 CdlegQ 11 -4 or 5.1 of working Me, even dreared) Teacher Elementary L} 16. FATHER -NAME FIRST MIDDLE UST 17, MOTHER FIRST MIDDLE MAIDEN SURNAME Fredrick Meyer Bertha Barth 18. WAS DECEASED EVER IN U.S. ARMED FORCES? t9a. INFORMANT - NAME (Yes no. or unk.) (Byes. give war and dates of services/ NO Harold M. Anderson 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP) 1033 Sheridan Alliance, Nebraska 69301 N. BALMER - SIGNATURE d LICENSE NO. 9 3 7 9 21a. METHOD OF DISPOSITION 7 21b. DATE 21c. CEMETERY OR CREMATORY - NAME ©moral ❑ Rer,gYal June 3, 1999 Alliance Catheter 22a'FUNERAL HOME - NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Bates -Gould Funeral Home ❑Crema"°n 1:1 Donation Alliance Nebraska 22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) P.O. Box 574 Alliance, Nebraska 69301 21 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Iai (b). AND Icl) I Interval between onset and death PART n^7� /� � (a) 2, e J 1 DUE TO. OR AS A CONSEOUENCE OF Interval between onset and death DUE TO, OR AS A CONSEOUENCE OF I Interval between onset and death I (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing 10 the death but not related P ART 111 IF FEMALE. WAS THERE A 124 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS, EXAMINER OR CORONERS II (Ages 10 -54) Yes No Yes No Yes No 263a. 26b. DATE OF INJURY (W. Day Yrl 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accdent Undetermined M Sti de Pending 26e. INJURY AT WORK PLLApCE QF INJURY - At home, farm. street, factory 26g. LOCATION STREET OR R D NO, CITY OR TOWN STATE ` ❑ Hominde tnvesligation Yes ❑ ❑ 126f o6ice building, etc (Speciy/ No J) 27a. DATE OF DEATH (MO. Day. Yr] 28a. DATE SIGNED /MO.. Day. Yr) 28b TIME OF DEATH > Ma 31 1999 aW M ' g 27b. DATE SIGNED (Mo. Day. Yr .I 27c, TIME OF DEATH 28c. PRONOUNCED DEAD (MO. Day. V.) 28d. PRONOUNCED DEAD (Hour, 4.00 AM of 9 M g8 2 27d. To tl1e best of my knowledge. death occurred at the lime, date and place and due to the 2Be. On the basis d examination anOra ilvestgation, in my opinion death occurred at F cause(s) stated. /'�.,, 9 (V () '�/rvr'V(�V- 6 a Bre ame. date and place and due to the causes) stated. 10, (S_ nature and Title 10 Lure and Tilt 29, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? 1:1 YES ® NO ❑ UNKNOWN ❑ YES r No ❑ YES NO TTT�� 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or Pdorl Anna Koscinska MD. 2107 Aox Butte 41vejw Alliance, Nebraska 69301 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (W,. Day. Yr.) 5f