|
STATE OF NEBRASKA
<br />.. A&tonw.tdtr n .itt4fltt vk V.,..rfosA44w1!hM$zi3-..::.no r@➢ db`➢ ,.>s'srrrA�OldDzzv
<br />41Ar))JtiN.
<br />'! WHEN THIS COPYCARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OR THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DArE OF ISSUANCE
<br />11.2024
<br />LINCOLN, NEBRASKA
<br />a
<br />202400 '33'
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1 CECEDENT"$ NAMI~ (First, Middle, Last, Suffix)
<br />Russel ;Blake Anderson
<br />CERTIFICATE OF DEATH
<br />4 CITYAND,$TATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebraska
<br />SOCIAL SECURITY NUMBER
<br />50840-.8012
<br />Ba. AGE • Last Birthday
<br />(Yrs.)
<br />610fACiLITY AME (if not institution, give street and number)
<br />Vetere�s Affairs Medical Center
<br />ii1T
<br />Sc. MY Qft'I'OWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />90.RESIDENCE Ave
<br />Nebraska
<br />9& STREET AND NUMBER
<br />2406 Riverview Dive
<br />9b. COUNTY
<br />Hall
<br />90
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />65, PLACE OF DEATH ;'i
<br />HOSPITALInpatient
<br />Q ER/Outpatient
<br />❑DOA
<br />10a MARITAI,iSTATUSAT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />11 FATNER S;f4AME (First, Middle, Last, Suffix)
<br />Albert Anderson
<br />13.;EVER IN AiLS ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or unk.) Yes 06/13/1956-06/12/1958
<br />16. METHOD OF DISPOSITION
<br />CJ Buda) []Don*tion
<br />Cren)ration { Entombment
<br />d Removal: Q Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo„ pay, Yr.)
<br />December 21, 24123
<br />8. DATE OF BIRTH (Mo., Day Yr.)
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />IBd. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />*Spice Facility
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give mai
<br />Janice Winter
<br />so. IN$Ips CITY LIMITS
<br />YES Q NO
<br />12, 1110THER'$.NAME (First, Middle, Maiden Surname)
<br />CSlpa Harps
<br />14a.INFORMANT-NAME
<br />Janice Anderson
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town,.state) •
<br />A)l I+aitha l=uneralHome 2929 S. Locust Street, Grand Island; Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />18: PART I. Enter the Chain of ave`- -diseases, Injuries or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a (Ins. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a)Adenocarcinoma of esophagus
<br />14b. REI.ATIONS1fIP'
<br />Spouse
<br />16c. DATE (410,,P
<br />December 2S 2023
<br />DECarietr .
<br />STATE
<br />aska
<br />iMM801A S Cki 36 tFInsl
<br />rlt8daae dr donttitrat tasuitlnp'
<br />In death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />a+:line a.
<br />EtgtF}'theUNDiRL.. YMKiCk1J3E
<br /><:
<br />IdNeA!bF at' Wiiry;het khgatea
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE
<br />ottsat tai d+a>t�
<br />18=Mouths
<br />TERVAL
<br />• onset to death:
<br />0
<br />It PART II OTHERSIGNI$ICANT CONDITiONS-Conditions contributing to the, death but not resultIng In the underlying cause given In PART I.
<br />AngitaarcOrtia of scalp, coronary artery disease
<br />2p. IF FEMALE:.
<br />Not prapnp'nt within put ye
<br />C]�*[ Pr great at time of decal
<br />L.i
<br />Q Mot y egnard but prp9toint within 42 days of death
<br />Q'. Not pregnant, but pregnant 43 days to 1 year before death
<br />Q, Unknown (fpregnent within the past year
<br />22a DATE OF IN
<br />URY (Mp„ Day, Yr.)
<br />22d. INJURY AT WO
<br />Q YES Q NO
<br />21a. MANNER OF DEATH
<br />® Natural Q Homrcide
<br />❑ Accident Q Pending kweetigatlon
<br />0 Suicide Could not be determined
<br />22b. TIME OF INJURY
<br />21b IF TRANSPORTATION INJURY
<br />Q Dnwrroperator
<br />:1"3 Passenger
<br />0 pedestrian
<br />Q Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED/
<br />Q YES NO
<br />21c. WAS AN AUTOPSY M>'ERF(
<br />Q YES N0
<br />MED?'
<br />21d. WERE AUTOPSY FININNG$ AAAI II.ABLE
<br />TO COMPLETE CAUSE OF DEATH?'
<br />Yes C No .. `
<br />22c. PLACE OF INJURYYAt home, faint, street, factory, office building, construction a
<br />226.DESCRIBE HOW INJURY OCCURRED
<br />A MON17F Ili IJRY'. STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 21, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 22, 2023
<br />CITY/TOWN`
<br />23c. TIME OF DEATH
<br />10:00 PM
<br />'retro beammi ntyknowledge, death occurred at the time, date and place
<br />OW dub to the:eause(s) stated. (Signature and Title)
<br />•
<br />Jennifer Kind, MD
<br />25. tip TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q YES1NO C] PROBABLY 0 UNKNOWN
<br />27. NAME, Tri%. ND ADDRESS OF CERTIFIER (Type or Print
<br />`Jennifer iKing, MD, 2201 N Broadwell Ave, Grand Island, Nebraska, 68803
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TI
<br />OE beam
<br />MP CODE
<br />24d. TIME PRONOUNCED mak#•
<br />24e. on the beele of examination and/or Investigation, in my opinion death esaun_ ,.
<br />thiSBMi4 date and place and due to the cause(*) state* iSlanature andTlle)'
<br />285. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES [ NO
<br />28a. REGISTRARS SIGNATURE
<br />L.
<br />26b. WAS CONSENT GRANTED? ..
<br />Not Applicable If 26a la NO n YES
<br />J
<br />28b. DATE FILED BY REGISTRAR (Mo., Day
<br />December 29, 2023
<br />❑ NO
<br />
|