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<br />STATE OF NEBRASKA
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<br />WHEN TKIS COPY CARNES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />AEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, V/1`AL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OP ISSUANCE:
<br />....................................
<br />6/2412022
<br />LINCOLN, NEBRASKA
<br />202204188
<br />(LA /3e, "Litiakivon,
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF 'HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DE9E9ONT S*NA(50 (Filar; ` Mi rile, Last, ' Suffix)
<br />Steven Graig Anderson
<br />4. CITY AND STATE OR. TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. St:1CIA(SECURITY.NUNtBER
<br />607 64.9123
<br />8b. FACILITY -NAME (if hot institution, give street and number)
<br />as
<br />ryan Medical Center East
<br />Sc.' Orly Tt am OF DEATH. (Include Zip Code)
<br />Lincoln 68506
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />$d. STREET Alloaumesa
<br />29 Chantilly Street ! .
<br />9b. COUNTY
<br />Hall
<br />10a. M.ARITALSTATUB AT TIME OF DEATH I1 Married 0 Never Married
<br />0 Married, but separated ` ❑ Widowed ❑ Divorced ❑ Unknown
<br />1. FATHERSNAME (First,
<br />Jerry Anderson
<br />I3. E1lERiN 1)9 ARMED FO
<br />(Yes, No, or Unk.) NO
<br />Middle, Last, Suffix)
<br />18, METHOD OF DISPOSITION
<br />❑:Btlriaf ❑Donation
<br />Orematitrtt ❑ Entombment
<br />❑`Removal- ❑ Ottter (Specify)
<br />ve dates of service if Yes.
<br />6L AGE - Last`.Birthday
<br />(Yrs.)
<br />69
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />6c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />89. PLACE OP DEATH
<br />HOSPITAL ® inpatient
<br />0 ERIOu patient
<br />DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />18d. COUNTY OF DEATH
<br />Lancaster
<br />HOURS
<br />MINS.
<br />22 07094
<br />3.DATE OF DEATH 4Mo,, Day,
<br />Mav 16, 2022::.n.
<br />e.1DATE OP BIRTH (Mo; Day,Yr.')`
<br />January' 6,.1.953
<br />OTHER 0 Nursing Home/LTC'❑#loep(ae.F
<br />❑ Decedent's Home
<br />Other (Specify)
<br />Oe. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />1Ob. NAME OF SPOUSE (First,' Middle, Last, Suffix) If wife, gi
<br />Kathleen A Eriksen
<br />12. MOTHER'S -NAME (First,
<br />Shirley Phifer
<br />14a. INFORMANT -NAME
<br />Ryan Anderson
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />BML Cremation Service
<br />19a. F11NERAL'f enii NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfet I~unetal Hiyme, 1123 W. 2nd, Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />Middle, Malden Sural
<br />CITY / TOWN
<br />Lincoln
<br />9g. 1N81DE OITY LtfA ttS '
<br />YE$ CI <MO
<br />14b. RELATIONSHIP TOE
<br />Son
<br />1ec. DATE (Mo.,.Day,Y
<br />Mav 19, 2022ff
<br />STATE
<br />Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />1S. PART 1. Enter the chain of events- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory,arreet, (*ventricular fibrillation without Showing the etiology. DO- NOT. ABBREVIATE, Enter only one cause ona line. Add additional lines if neceas
<br />IMMEDIATE CAUSE:
<br />imiAEDIAT65. 55 (Pins! ` a)ACU#e liver failure
<br />dtaaapa or coalition reeuling:
<br />M death) DOE TO, OR AS. A CONSEQUENCE OF:
<br />Sequentially asfsontlitiade, if b) Endstage liver disease due to cirrhosis of liver.
<br />Arty, leading to tha,cauee:8sted
<br />on
<br />311e8 DUE TO, OR ASA CONSEQUENCE OF:
<br />ErdarUleUNDEtt 1NC:c0A E c)
<br />misaaa or Injety:,thet4nia ect .;
<br />:the aviitits resoling Is death) DUE TO, OR ASA CONSEQUENCE OF
<br />LAST
<br />d)
<br />18. PARTII ;OTHER SIONIFiCANT CONDITIONS-Conditlons contributing to the death but nO resu ting In thatlnderlying cause given in PART I.
<br />Metastatic pi'astate cancer, hypoalbuminemia, anasarca, acute severe::sepsis with€septic shock
<br />20. IF FEMALE:
<br />Not pregnant.altMn past year
<br />Qr� Pregna t ne of 8eaffi
<br />❑ katpregntaaltt but pregnant Wtthtn 42 days of death''
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />' ❑ Unknown 1#'psegnant Within lite peat Haar
<br />22a. DATE 'OF NJ
<br />22d. INJURY AT WORK?
<br />❑YES CINO
<br />21a. MANNER OF DEATH
<br />Natural ❑ de
<br />Accident ❑ Pending ImCaltigatlan
<br />❑ 8uie de ❑Could not be tletermined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Dor/liar/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />19b $lp Coda j;
<br />88801•
<br />APPROXIMATE EATERYAL
<br />MOM*.
<br />Few. -mow.
<br />onset to death
<br />Few Months
<br />et t31(i'' th
<br />onset to death
<br />19. WASMEO1CALEXAMINER:'.
<br />OR CORONER CONTACTa0?
<br />❑ YES Iii NO
<br />21c. WAS AN AUTOPEYP5
<br />• ❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVANA
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES1:1. NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, atC {Spg )
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OF INJURYi�STREET& NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OFDEATH (Mo., Day, Yr.)
<br />• May 16, 20221•'
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Mav 17, 2022• 03:00 PM
<br />d. To the bout Of my knowiedge,'death occurred at the time, date and place
<br />and due to thecause(s) stated.. (Signature and Title)
<br />Vivek Kulkarni, MD
<br />25. DID TOBACG;O USE CONTRIBUTE TO THE DEATH?
<br />( YES IR 0 PROBABLY 0 UNKNOWN
<br />27ME, TITS E Nil ADDRESS OF CERTIFIER (Type or Print
<br />Vivek KUlkarni, MD, 2300 S 16th, Lincoln, Nebraska, 68502
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH.
<br />24d. TIME PRONOUNCED DEAD:,.
<br />24a. On the kasis of examination and/or Investigation, In my opinions dea8geddllnedat:
<br />the time; date and place and due to the cause(s) stated. (Signature and'IMe1
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />® YES 0 NO
<br />28a REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a le NO 0 YES Ntl
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 19, 2022
<br />N
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