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<br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECOR"W SINTH.
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />rl�A bOPEft
<br />OCT 13 2000 ASSISMWS r =-
<br />LINCOLN, NEBRASKA HEALTH AND HU1W gY3tEIN
<br />200010326 - --
<br />-
<br />STATE OF Nt=ASU- DEPARTMENT OF HEALTH
<br />BUR ""VITAL STATISTICS % 8 ` 9 ` L 9
<br />CERTIFICATE Of DEATH :.,.
<br />DECEDENT —NAME ':. . FIRST - MIT)DLE' , ". .; ., T -
<br />EX
<br />DATE Of DEATH (Me -. D ►r.) ,
<br />Arthur Anderson
<br />Male
<br />t 1978
<br />I
<br />2
<br />, 9,
<br />RAGE— (e.y., Wbise, Nock Maericaw ORIGIN /DESCENi(e. y.. fgGon.ANeicew, AGE —ter R.wbd.P
<br />UNDER 1 YEAR UNDER 1 DAY DATE OF BIRTH (M... Dor, Y..)
<br />&thaw t(. Gereww,eN.)(Spec./T) r n
<br />MOs. DAYS F HOURS MINS t /fit
<br />!u k•'' r. Rte,: ;..� i ° "A 4l
<br />_.
<br />_ d _" a w, i)i� :.,„ M(; `' T: - 60. -
<br />CITY AND STATE OP fIRIM(Ftad:w U.S.A.,', CITIZEN
<br />OF -W/IAT OUMTRY .
<br />MARRIED. N ER MARRIED, • -
<br />NAME Of SPOUSE.( .di.:yive e,oid„ "'C"'st 'I
<br />co.wir,) ,;. r-
<br />WIDOWED. DNORCED(Sp.cif,)
<br />B Callay - Ne. v.
<br />USA Ro
<br />2'Sarri
<br />Hazel rlurr Anderson
<br />SOCIAL SECUNTY NUMBER ' USUAL OCCUPATION (G" kind of-ork done cf Noy iI oo
<br />KIND OF BUSINESS OR INDUSTRY
<br />COUNTY OF DEATH
<br />L . ofwwkiny lib, 0.ew if retired)
<br />1 06a- 2 -2 66 'I3a Retired Farmer 4 = t
<br />13b Farmin
<br />Reo Hall
<br />CITY, TOWN OR LOCATION OF DEATH INSIDE
<br />CITY LIMITS
<br />HOSPITAL OR OTHER INSTITUTION — None (If —1 ie .0h." IF NOSP OR INS? I.dK. DOA.
<br />(Sped/,
<br />Yes or No)
<br />OrryW...IEn.. e. .Lwow.+. riw«dr,
<br />yi.. F /reel owd wew.6er)
<br />Ieb. Grand Island t•C:.
<br />Yes'.
<br />Ned. Lakeview Nursing Home Rs.. Intiatieat
<br />RESIDENCE -STATE ,_ {OUNTY . -:-
<br />CITY, TOWN OR LOCATION - STREET AND NUMBER - INSIDE CITY LIMITS
<br />. ,:_.
<br />", (Speei+�
<br />Iso. Nebra&q Tsb.
<br />-YS
<br />,x. iiTBil$ I land Isd 08 East a ital Rs.. Y s
<br />FATHER—NAME 1 E - LAST ::
<br />MOTHER - MAIDEN NAME FIRST MIDDLE U
<br />16 A3
<br />117, zem
<br />WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />INFORMANT — NAME — RELATIONSHIP— MAKING ADDRESS (STREET W RFD nIf OlUf)Wl LATE. ZIP)
<br />11 VV�O �UII//1l.
<br />,'Y.., .•. er r.•){(it �.r. ,..e .w ood d.... W +..•...)
<br />.# i.`.Z+ Y�`ii oy
<br />16. 140 i ..,.
<br />19 _ - .,. ;. _e.', Grand Island)
<br />BURIAL,. Creewnowi
<br />DATE
<br />CEMETERYOR.CREMATORT -NAME ';? -.•'
<br />LOCATION CITY OR TOWN STATE
<br />2o.. Burialil
<br />20b.t3111/78
<br />20c. Grand Island (City
<br />20d Grand Island NE
<br />EMSAIyEI —SIGN TORE i LICENSE N
<br />18201
<br />FUNERAL NOME —NAME AND ADDRESS (STREET of R f o. NO. CITY oR TOWN. STATE. 2v)
<br />88ol
<br />ston -Sondt rmann/ s 5Oj 11.KoeniL_; Gran Ia_;at ci i +e
<br />21
<br />221i
<br />I«...d dr. M 0-
<br />o.
<br />0- bow .r ..ew:..u« o,di- M wr .Pm;— a Z►...d W
<br />n3
<br />23o.(Si,.eA.. ..I /A. ) �
<br />A�..
<br />vY 2eo
<br />y(
<br />_ ^>
<br />DATE NEO(Mo_ Day, r.) _ HOUR OF DEATH 2-� }
<br />A 1 IMO. o,, r.
<br />OUR
<br />v
<br />236 23c. �'�-�- � M 24b.
<br />241.
<br />_
<br />Do,, Yr.)
<br />PRONOUNCED DEwD(Hour)
<br />E
<br />•
<br />DATE OF DEATH (Me-. De,, Yr.) ►ROHOUNCEOOEAD
<br />° (Mo.,
<br />a<
<br />23d aA 3d
<br />RTIFIER (PHYSICIAN, CORONER'S ►HTSICIAN OR COUNTY ATTORNEY) (T,pe or Ir.wl)
<br />2 A. E. 7anWie, Id. D., 717 W. Anna Ste, Grand Island, lie.
<br />REGISTRAR
<br />D BY REGISTRAR (Mo.. Da,, Yv.)
<br />?M.rb,.•..nll►
<br />,.w .
<br />IMMEOIAT U ( O t ON CAM PER ONE Ob(o), (bl. AND (c)) L.. I bs Wand d.wal
<br />PART
<br />DUE TO, Olt AS A CONS9TIFERCE OF L..�.( ►a.....ur .,d s«+
<br />DUE 10, OR AS A CONSEQUENCE OF _ I.....o, ►•" �." «.w ..e do**
<br />PABT A + S - CooIdolom cMFlb.h., N dM(b b.# .0 ..$.led FART (It. (1 FEMMI WAS TNEEI A AUTOPST -TWA$ CASE 11110110 TOW AL
<br />;ART 1H� PASI S MONINST (10"Pt ►.. N.) IEAMINIR W CORONIR
<br />B (SP -11, Uc.. No)
<br />1 Yes [ me L I 2 20
<br />ACC im. "0wCIDE, uNOET ,. DAtt Of IHIURY (M.., D.I. Yr l NOUe of 1N/u1Y O/SCR/RI HOW uuuIY OCCu"to
<br />ON FINDING INYESTI""O" op.cbl
<br />1309,
<br />306. M 30d.
<br />IRH11Y AT WORD
<br />_
<br />KALE OF e41I41, - M h.—. ..a, 11kowl, #_ y.
<br />LOCATION stRlll OR 1 P D He CITY 00 TOWN STAIR
<br />(sp•rd, YN • Me)
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