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rn 2 D <br />rn N <br />� _ <br />f1 Z <br />n <br />n S N f-+ ca <br />rr7 } ,;RM —i f�7 <br />�Qi fV Q _n <br />M �� "� r► m <br />E� riX in a C <br />OR <br />c <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND H' <br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECf� <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE_ - <br />10 2 N cc� <br />JN 22 2001 200106 _ <br />ASS/STAN_T. STATEREGI$TR�FR <br />L7 OLN, NEBR�311(�4 HEALTH AND HUMANSERWICErgS1�fi>£(, <br />A OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE ANi73`LJPFORi <br />VITAL STATISTICS 00290 <br />CERTIFICATE OF DEATH <br />DECEDENT - NAME FIRST MIDDLE LAST <br />2 SEX <br />3 DATE OF DEATH /Month. Day Yearl <br />Lawrence Juel Anderson <br />Male - <br />January 6, 2001 <br />CITY AND STATE OF BIRTH U(norin USA.. namecountry) <br />5a AGE - Last Blnhday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />16 . DATE OF BIRTH (Month. Day Year) <br />5b MOS ' DAYS <br />5c HOURS MINS <br />Osceola, Nebraska <br />"s84 <br />November 13, 1916 <br />SOCIAL SECURTIY NUMBER <br />Be . PLACE OF DEATH <br />508 -14 -5051 <br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home <br />Not Embalmed <br />❑ ER Outpatient ❑ Residence <br />b FACILITY - Name /it not msatunch. give street and number/ <br />Lakeview Nursing /Rehab Center <br />❑ DOA ❑ Other (Specify, <br />c CITY TOWN OR LOCATION OF DEATH Bo INSIDE CITY LIMITS <br />Be COUNTY OF DEATH <br />Grand island, Nebraska Yes 2] No ❑ <br />Hall <br />a. RESIDENCE STATE <br />9b COUNTY <br />9c CITY. TOWN OR LOCATION <br />9d STREET AND NUMBER /Including Zp Code) <br />9e INSIDE CITY LIMITS <br />Nebraska <br />all <br />Grand IS <br />1924 W 13th 68803 <br />Yes ® No ❑ <br />0 RACE - le.g, While . Black. American Indian <br />t 1. ANCESTRY Is g, Italian. Mexican. German, etc] <br />12. ❑ MARRIED ® WIDOWED <br />13 NAME OF SPOUSE /it wile give maiden name) <br />etci:SDeoly) <br />White <br />ISoec,tyl <br />American <br />NEVER DIVORCED <br />MARRIED <br />Lillian M. Wagner <br />4a USUAL OCCUPATION /Give kind of work done during most <br />t4b KIND OF BUSINESS INDUSTRY <br />115 EDUCATION (Specify only highest grade completed) <br />Elementary j$ condary (0 -12) College It a or s -I <br />B1yC8ff61 MM <br />V.A. Hospital <br />6 FATHER -NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Arvid Anderson <br />Katherine Zimmerman <br />8 WAS DECEASEU EVEH IN U S AHMEU YUHL;Lb! <br />i 19a. 1—UHMANI - NAML <br />2A AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />°fees9war1942pISe10 6 -1945 <br />IRoger Anderson <br />EXAMINER OR CORONER? <br />P <br />9b INFORMANT MAILING ADDRESS (STREET OR R F 0 NO CITY OR TOWN STATE ZIPI <br />ZI <br />1303 North Grand Island Ave <br />Grand Island, Nebraska <br />68803 <br />Yes No <br />0 EMBALMER. SIGNATURE 6 LICENSE NO <br />21a METHOD OF DISPOSITION 211) DATE <br />26c HOUR OF INJURY <br />21c. CEMETERY OR CREMATORY NAME <br />Not Embalmed <br />❑ Burial ❑ Removal Jan. 6, 2001 <br />Central <br />Nebraska Cremation <br />2a FUNERAL HOME NAME 1 <br />M <br />21, CEMETERY OR CREMATORY LOCATION <br />CITY OR TOWN STATE <br />Apfel- Butler - Geddes <br />RC-a-, ❑ Donarnr <br />I <br />Gibbon, <br />Nebraska <br />'2b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. <br />STATE. ZIP) <br />1123 West Second Street Grand <br />Island, Nebraska 68801 <br />273 DATE F DEATH /MO. Day. Yrl <br />'3 IM IAT MED AUSE (ENTER ONLY ONE CAUSE PER LINE FOR :ai ibl. AND Icli <br />28b. TIME OF DEATH <br />_ <br />Interval between onset and deal, <br />PART <br />I ia' l��.l y //' L.Gi.� `- C /r /!Y�� <br />M <br />I..- ._•_�vy�� /`� -K�'/ <br />DUE Tb/O /— /L.A/S 7Ar,, ONSEOUENC`E OF <br />Ibl / , !�I -Qi✓ �� dCXX�/ �t. \�.1i7 (/_4�` �' J�,�^-"_" `—_ /.� % w � <br />DUE TO OR AS A CONSEOUENCE OF <br />Interval between onset and deal, <br />I _ <br />Interval petween onset and peal, <br />I <br />II <br />OTHER SIGNIF1 7 C� NS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A <br />2A AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS' <br />EXAMINER OR CORONER? <br />P <br />ZI <br />(Ages 10 -54) Vey ND <br />Yes N <br />Yes No <br />!68 <br />25b DATE OF INJURY (Mo. Day Yr) <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />M <br />Swatle Pending <br />26e. INJURY AT WORK <br />261. P�ACE Of WJURV . At home. farm. street. factory <br />26g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE <br />Homicide Inveslgalio^ <br />Yes[:] NO ❑ <br />oMice building, etc /Specilyl <br />273 DATE F DEATH /MO. Day. Yrl <br />28a. DATE SIGNED /Mo.. Day. Yr.) <br />28b. TIME OF DEATH <br />$ n y <br />M <br />y <br />27b DATE SIGNED (Mo Day YU <br />27c. TIME OF DEATH <br />28c PRONOUNCED DEAD tMO.. Day. Yrl <br />28d. PRONOUNCED DEAD (Hour <br />4:47 A <br />E <br />M <br />. <br />�° 0 <br />M <br />27d To the best of my kno etlge. each occurred at the time, tlate antl Olace and tlue to the <br />2Be. On the basis M examination and or investigation, in my opinion death occurred at <br />causels) slated . 1 �! <br />the time date and place and due to the cause(sl stated. <br />ISi nature and Title ► ( <br />(Signature and Tlae ) ► <br />.9 DID TOBACCO USE CONTRI TO THE DEATH' / <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />❑ YES NO UNKNOWN l <br />❑ YES NO <br />❑ YES NO <br />31 NAME ANUAUUHESb UkL:LHI RICH (WHY JIL,IAN,L.UHUNtHJ YHYJIL;WN UH UVUN I, A I I VHNtY1 I yus -oll <br />Dr. John A. Wa oner Jr. 800 Alpha Grand Island, Nebraska 68803 <br />32a gEGISTR 32b DATE FILED BY REGISTRAR (MO.. Day Yyj <br />„� ", JAN 18 2001 <br />rn <br />o co <br />N Ct� <br />d <br />O <br />O Cn <br />Cn <br />O � <br />O C <br />H D <br />N c <br />HH m H a ro <br />m a N p a <br />F- tr• h <br />a u. 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