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WHEN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HIRVICES SYSTEl14 IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R9C01WWtFALE VATH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC$P#ION; !_l THE LEGAL DEPOSITORY FOR VITAL RECORDS A K ,Gta DATE OF ISSUANCE - - MAY 2 01998 200412122 ASSISFJ Isrl LINCOLN, NEBRASKA HEALTH AND HUIiN 51zFSIS�TEM_ STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERV[Cgiwm fi A%HT ICI&t VITAL STATISTICS - Amandarl Mav 9n- 1 99R r.F.RTTFTC.ATF. OF T)FAT 4 1. DECEDENT - NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH (Mont. Day Year) Elsie Fay Sanders Female May 04, 1998 a CITY AND STATE OF BIRTH (Nnot h USA.. name couney) Sa. AGE - Last Birthday UNDER 1 YEAR UNDER t DAY 6. DATE OF BIRTH (Month. Day Year ' 5b. MOS. DAYS Sc. HOURS' MINS. (Ages 10 -541 Yes No (Ys,) May 15, 1908 St. Paul, Nebraska 89 26c. HOUR OF NJURY 26d. DESCRIBE HOW INJURY OCCURRED y SOCIAL SECURTIY NUMBER Ba. PLACE OF DEATH HOSPITAL Inpatient OTHER. Nursing Hone 506 -09 -4846 code Pending 26e INJURY AT WORK ER Outpatient Residence FACILITY -Name (lynot m irklian giveseeer ant nmber I Lakeview Nursing Center DOA ❑ Other (Specty CITY TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island Yee ❑X Nd ❑ Hall I 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER Iklcludirg z4D Codel 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 1405 West Highway 34, 68803 Yes ❑ No ❑ 10. RACE - (e.g., While, Black, American Indian. 11. ANCESTRY le 9. Italian. Mexican. German, etc) 12. ❑ MARRIED � WIDOWED 13. NAME OF SPOUSE /N wAe. give maiden name) etc.) lSpeafyl White ISpecMl American NEVER DIVORCED Ira J. Sanders 14a. USUAL OCCUPATION (Gwe kindd work done dwtg most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) Ebme�t�(y o Secondary 10. 121 College I1 -4 015-1 d working I /le. even / net red/ Home Maker Domestic Ij 16 FATHER --NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Stewart Ware I Stacia Myers _ 18 WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT NAME (Yes no. or unk.) III yes give war and dales of services) Dan No I _ - 0o*Sanders _ 19b INFORMANT MAILING ADDRESS (STREET OR RIF.D. NO., CITY OR TOWN STATE. ZIP) 4515 60th St., Columbus, Nebraska 68601 2G. BALMER - SIGN,4 RE 8 LICENS 21 a. METHOD OF DISPOSITION 21b. DATE . CEMETERY OR CREMATORY NAME /Q % 121C ❑X ❑Removal 05/07/1998 Elmwood Cemetery Buria 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE 226-FUNERAL HOME - NAME Apfel - Butler- Geddes Funeral Home ❑ Crenl.an ❑ 1q^ St..Paul, Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. 110 CITY OR TOWN. STATE, ZIP) 1123 West Second Grand Island, Nebraska, 68801 -5899 PART p 1� I (i A ` x DUE TO, OR AS A CONSEGUENCE OF Interval between onset and deatn (b) I e a I I Interval between olsel and seam I (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death bill not related P ART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER' 11 (Ages 10 -541 Yes No Yes No Vey NO 26a 26b. DATE OF INJURY IMO. Day. Y.) 26c. HOUR OF NJURY 26d. DESCRIBE HOW INJURY OCCURRED ❑ Accident Undetermned M code Pending 26e INJURY AT WORK 261, PLtAACE OF INJURY - At 1gn7. farm. street. factory boldug. etc. lSPeeMI 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ oHKe I 27a. DATE OF DEATH\ (Mo. Day Yrl 28a. DATE SIGNED (Mo.. Day. YO 28b TIME OF DEATH M uU_i 27D. DATE SIGNED (MO. Day Y,r�) 27c TIME OF DEATH 280. PRONOUNCED DEAD (Mo.. Day, Yr) 28d. PRONOUNCED DEAD /Fowl a0 T% (�) OJ `.' } iv M ° 27d. To the best of my k occurred lime, date a pi e and due to the `x 28e. On the basis of examination aMror investigation, in my opinion death occurred at the time. dab and due to the cause(sl stated. o c O a causes) stated. a \\ �/� ISi nature and Title) ► � :� �� `Z yJ place and a and Tide 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ .YES NO ❑ UNKNOWN ❑ YES �NO El YES NO 31. NAME AND ADDRESS OF''YCCEE'R^RTTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( (Type or Pnnt) Dr. John J. Cannella, 729 N Cqjter, Grand Is)knd,, Nebraska 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR 10116. Day. Yr) MAY 7 19-918 u If