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WHEN THIS COPY CARRFES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RF.G0 Zf V FILE Irl/ITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTl0d3C f WWH_ ICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE - 2"403853 A 0.404= <br />MAY 8 2002 ASSISTAtff ware= Md1§T( _= <br />LINCOLN, NEBRASKA HEALTH AND HUNAN SERVICES-SY0119llU <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE A3VD SUPPORT <br />VITAL STATISTICS - _ _ � <br />CERTIFICATE OF DEATH - 0 � 05257 <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2 SEX <br />3. DATE OF DEATH tMonth Day Year; <br />Donald Charles Anderson <br />Male <br />April 28, 2002 <br />4, CITY AND STATE OF BIRTH r1fdot n USA.. name countryi <br />Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH !Month. Day. Year) <br />Hastings Nebraska <br />T-AGE- <br />(Yrs) 60 <br />5b MOS DAYS <br />Sc HOURS MINS <br />January 10, 1942 <br />7. SOCIAL SECURITY NUMBER <br />8a. PLACE OF DEATH <br />505 -56 -5354 <br />HOSPITAL: Inpatient OTHER ❑ Nursing Home <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY - Name (It not Institution, give street and number/ <br />Mary Lanning Memorial Hospital <br />❑ DOA ❑ other ISPe0v <br />Bc. CITY. TOWN OR LOCATION OF DEATH <br />Bd INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Hastings <br />Yes ® No ❑ <br />Adams <br />9a. RESIDENCE - STATE <br />91b . COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER /Including Zip Code) <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Adams <br />Hastings <br />1254 Heritage Dr., 68901 <br />Yes ® No ❑ <br />10. RACE - Ile g., White. Black. American Indian. <br />11. ANCESTRY le.g.. Italian. Mexican. German, etcl <br />12. K] MARRIED F-1 WIDOWED <br />73. NAME OF SPOUSE Of wile give maiden name/ <br />etc. ISeecry <br />V�hite <br />is_c l <br />Danish <br />NEVER DIVORCED <br />MARRI <br />Pat A. Mapes <br />14a. USUAL OCCUPATION /Give kindot work done during most <br />141b KIND OF BUSINESS INDUSTRY <br />15. EDUCATION <br />(Specify only highest grade completed) <br />Elenryly or Secondary (0 12) College 11 4 or 5 <br />11 LL 'i <br />of working life, even it relined! <br />Hospital <br />Director .J <br />2 =II <br />16. FATHER - NAME FIRST MIDDLE LAST <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Vern C. Anderson <br />Golden Rule <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES' <br />19a INFORMANT -NAME <br />(Yes no or unk.l III yes give war and dates of services) <br />No <br />I <br />Pat Anderson <br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D NO_ CITY OR TOWN. STATE. ZIP) <br />1254 He itage Dr., Hastings, Nebraska 68901 <br />. EMB LME SIGNATURE BUCENSE <br />21a METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />1210 <br />E] Burial ❑ Removal <br />05/01/2002 <br />Parkview Cemetery <br />L HOME - NA <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livingston- Volland Funeral Home <br />Livingston- <br />❑ Cremation ❑ Donation <br />Hastings, NE <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE. ZIP) <br />1225 N. Elm Ave. Hastings, NE, 68901 <br />23. m <br />I CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. (b). AND Ic)) Interval between onset and neala <br />PART <br />( ( I <br />DUET , OW DNS EOU NC OF Interval between onset and seam <br />(b) <br />DUE TO /.�Q'JR�ASA COL /ry$E.O�U /f�•,JrCEL /Q�F interval cetween onset and deal) <br />Mir <br />O HERS CANT CO ITIONS - Contlitions comributing to the death but not related PART <br />III IF FEMALE. WAS THERE A <br />24 AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER'( <br />(Ages 10 -54) Yes NO <br />Yes No <br />Yes 0 No <br />26a. <br />26b. DATE OF INJURY /Mo. Day. Yr/ <br />26c HOUR OF INJURY <br />26d. DE FIRE HOW INJURY OCCURRED <br />❑ Acadent [] Undetermined <br />M <br />Suicide F-1 Pending <br />26e. INJURY AT WORK <br />261. PLACE OF INJURY - At home. farm. street. factory <br />26g. LOCATION STREET OR R.F.D NO CITY OR TOWN STATE <br />Homicide Investigation <br />❑❑ <br />Yes No ❑ <br />office building. etc /Specify) <br />27a DATE OF EfATH jj#o _ Day YrJ <br />28a DATE SIGNED /MO.. Day. Yr I <br />28b TIME OF DEATH <br />`f fig' Oa <br />rV= <br />M <br />g= <br />a <br />271b . DATE SiGNED 11M. .. Day. Yr) <br />27c TIME OF DEATH <br />28c PRONOUNCED DEAD IMO. Day. Yr.l <br />28d. PRONOUNCED DEAD /Hour( <br />y <br />1736 P M <br />2 =II <br />M <br />27d To the best of my kn wledge. each oc rred aft ti date and a and due to the <br />cause(sl stated. <br />28e. On the basis of examination and or investigation. In my opinion death occurred at <br />the time. date and place and due to the causelsl slated. <br />° a° ° <br />° <br />(Signature and Title) ► <br />ISI nature and Title <br />29. DID TOBACCO USE CONTRIBUT THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONAT BEEN CONSIDERED? <br />S❑ <br />30.b WAS CONSENT GRAN 7 <br />❑ YES NO ❑ UNKNOWN <br />NO <br />UTIIES ❑ NO <br />J7. NAME ANUAUUHtJJ OF UtH I IFILH IYHYbIUTAN,UUHUNtHJ HHYJIUTAN UHUUUN I Y A I I U-T) tiype -du <br />Paul C. Wibbels <br />32a. REGISTRAR 32D. DATE FILED BY REGISTRAR (A40, Day Yr.) <br />ra4761"" <br />MAY 6 2002 <br />