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V <br />M i D <br />C r) _ <br />r D <br />�r) C/) <br />_ry r <br />n, <br />� v <br />o 0 <br />�z <br />o <br />CD <br />r-F <br />o � <br />D <br />CD <br />CD <br />� O <br />r" <br />O <br />'-h <br />^^� 0 <br />CD <br />C <br />Q. Q <br />I" -N <br />rA <br />n o <br />O A <br />r �7 <br />c� C1 U <br />o Q <br />z -+ to <br />M <br />C) o N <br />Ca *t <br />s � <br />-o r� o <br />cn CD C <br />cn (n co <br />a <br />WMN IM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SOrAed& . -= <br />SYSTEM, IT CERTFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORD ON FJLE* H_- _ _ _ <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECi7 <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS sC _ <br />DATE OF ISSUANCE 47- a <br />0400298 )4�AktyE ` = <br />5/22/2003 20 - -- <br />ASSISTANT SM ft R00ftTRAft <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SEOIdICog"TIEM . == <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FIWAPI _ a n r <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH - l 1 5 O <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2, SEX <br />3. DATE OF DEATH (Month Day. Year/ <br />Alvin Hans Andersen <br />4. CITY AND STATE OF BIRTH (f/not in U.S.A.. name country) <br />5a. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. ATE OF BIRTH 146. Day. Year/ <br />Dannebrog, Nebraska <br />(Yrs.) 5b. <br />80 <br />MOS. i DAYS <br />5c. HOURS MINIS. <br />October 13, 1922 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />354-16-2009 <br />HOSPITAL: ® Inpatient OTHER: ❑ Nursing Home <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY -Name /f/not msfitubon, give street and number) <br />. <br />❑ DOA ❑ Other ISpecdvr <br />N OF DEATH <br />8d INSIDE CITY LIMITS <br />8e. OF DEATH <br />Grand <br />Grand Island <br />Yes ® No ❑ <br />Haill <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY, TOWN OR LOCATION <br />9d. STREET AND NUMBER pncfudtng Zip "98803 <br />11716 <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />N. Kruse Ave. <br />Yes ® No ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />11. ANCESTRY (e-g.. Italian. Mexican. German, etc) <br />12. ® MARRIED ❑ WIDOWED <br />13 NAME OF SPOUSE td wife. give maiden name) <br />etc.)fSpecify) White <br />(Spec'fy) Danish <br />NARER DIVORCED <br />Donna J. Christensen <br />14a. USUAL OCCUPATION /Give kind of work done during most 14b. <br />KIND OF BUSINESS INDUSTRY <br />TIO N (Specify only highest grade completed) <br />o/wdrki li/e, i /retired! <br />Foo -aworker <br />Veteran s Home <br />[IL.DUI.1 <br />emetor Secondary 10 -12) College 11 -4 or 5-1 <br />1 <br />16. FATHER - NAME FIRST MIDDLE LAST 17 <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Hans Peter Andersen <br />Hulda Johnson <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? WWII <br />19a. INFORMANT -NAME <br />)Yes. no. or unk.) 0f yes. gave war and dates of services) <br />Yes - 16-26-44/6-6-46 <br />Donna J. Andersen <br />191b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CRY OR TOWN. STATE ZIP) <br />1716 N. Kruse Ave. Grand Island, NE 68803 <br />20. EM BAE IGNATUREBLICEO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. CEMETERY OR CREMATORY NAME park <br />®Burial ❑Removal <br />El Cremation ❑ Donation <br />April 28, 20 3 Westlawn Memorial <br />22a. F NERAL HOME - NAME <br />/ Hom el <br />Jacobsen- Greenway� <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Grand Island, Nebraska <br />unera <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN. STATE. ZIP) <br />411 "O" St. St. Paul, Nebraska 68873 <br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (ad. (b). AND (cl) Interval between onset and death <br />PART <br />I <br />I <br />- 4DUE TO,OR AS A CONSEQUENCE OF Interval between onset and death - <br />Cvw�*wL -w^ r I <br />Ibl <br />I <br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset ana death <br />I <br />(c) <br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />25, WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />II /! n ,p� j �'ylw + I ....i n L <br />l� <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />i (Ages <br />�OF`i <br />10 -54) Yes No <br />Yes No Yj <br />Yes No <br />26a. <br />28b. DATE INJURY JJ`.- Day. Yr.) <br />26c. HOUR OF INJURY <br />2Ed. DESCRIBE HOW INJURY OCCURRED <br />u Accident F-1 Undetermined <br />M <br />Suicide 1:1 Pending <br />26e. INJURY AT WORK <br />26f. PLACE RF. JURY %Atthhou. farm. street. factory <br />ce bm dr etc. <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes No <br />❑. ❑ <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />28a. DATE SIGNED (Mo.. Day Yr l <br />28b TIME OF DEATH <br />a <br />M <br />27b. DATE SIGNED (Mo.. Day. Yrl <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD (Mo.. Day, Yr.) <br />28d. PRONOUNCED DEAD (Hour) <br />v'S <br />HE <br />"' 0 <br />go <br />g8 <br />M <br />o <br />mz8 <br />M <br />€ <br />° ° <br />~ <br />27d. To the best of my knowledge. death occurred at the time, date and place and due to the <br />28e. On the basis of examination and,or investigation, in my opinion death occurred at <br />cause(s) slated. n - -L � <br />/IJVf'h�Aw^ ♦' <br />° <br />the time, date and place and due to the cause(s) stated. . <br />ISi nature and Title ► l <br />(Signature and Title) 1� <br />29, DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a <br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b <br />WAS CONSENT GRANTED? <br />YES ❑ NO ❑ UNKNOWN <br />❑ YES I> <br />- '''______ <br />❑ YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEYI (Type ar Pnntl <br />Anne Morse MD 729 N. guster .Ave Grand Island, NE 68803 <br />32a. REGISTRAR a. <br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) <br />MAY 12 2003 <br />u <br />