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- �. <br />WHEN THIS COPYCARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH.( R�1AR�RVICES <br />SYSTEM, 1T CERTFIES THE BELOW TO BE A TRUE COPY OF THE OR/G � MAH,Lr`WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST � 3i"M IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS = _ _ <br />DATE OF ISSUANCE_ ' <br />JIBE &CSR <br />DEC 2 41997 200412122 <br />LINCOLN, NEBRASKA HEALTH ANOM_ 4 RVMSYSTEM <br />STATE OF NEBRASKA - DEPARTMENT OFVIE►LTfF <br />BUREAU OF VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />t. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH /Month. Day. Year/ <br />Ira Joel Sanders <br />Male <br />December 11, 1997 <br />4. CITY AND STATE OF BIRTH (M naf In U.S.A. rnanns eotamYl <br />Ss. AGE -Lest BiNnday, I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Month. Day. Year) <br />MOS. I DAYS <br />5c. HOURS' MINS <br />Batavia, Arkansas <br />(Yrs.) 89 Sb <br />August 17, 1908 <br />7. SOCIAL SECURTIY NUMBER <br />506 -03 -3567 <br />6a. PLACE OF DEATH <br />HOSPITAL: ❑ Inpatient OTHER: ® Nursing Home <br />❑ ER Oulpiabera ❑ Residence <br />8b. FACILITY - Name (I rid iinadi f/sM qw sasat and manbarl <br />Lakeview Nursing Center <br />❑ DOA ❑ Other (Specifyl <br />ec. CITY. TOWN OR LOCATION OF DEATH <br />8d. INSIDE CITY LIMITS <br />as. COUNTY OF DEATH <br />Grand Island <br />Yes © Nd ❑ <br />Hall <br />Be. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (hc)udhg Zip Cade) <br />9e. INSIDE CRY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />1 1405 Highway 34, 68801 <br />Yes ® No ❑ <br />10. RACE - (e.g., White. Black. American edian. <br />Wel <br />I 11. ANCESTRY (a g., Italian. Mexican, German, etc/ <br />=rican <br />12. MARRIED ❑ WIDOWED <br />NEVER D DIVORCED <br />13. NAME OF SPOUSE /a wr/e give ma/d[m name/ <br />Elsie Fay Ware <br />14a. USUAL OCCUPATION (O ve katd o(wipfil done dtirM mast 14b. <br />KIND OF BUSINESS INDUSTRY �,(� <br />15. EDUCATION <br />(Specify oruy highest grade completed) <br />Ebmenhry or Secondary 10 -12) College [1 -4 or 5.1 <br />12 <br />d wnrkag IM, even Arslvso <br />Serviceman <br />%" i / <br />Power Company <br />16. FATHER -NAME FIRST MIDDLE UST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />William D. Sanders <br />Addena Balcom <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT -NAME <br />(Yes. no or ur* I Ill yes. give war and dates d services) <br />No <br />Elsie Sanders <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />1405 Highway 34, Grand Island, Nebraska 68801 <br />20.E LMER- SIGNATUR LICENSE NO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />#1071 <br />❑ Bunal ❑ Re.al <br />12/15/1997 <br />Elmwood Cemetery <br />NERAL HOME - NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- Butler- Geddes Funeral Home <br />❑ aemauon ❑ Ddnanon <br />St. Paul, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />1123 West Second Grand Island, Nebraska, 68801 -5899 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). (bl. AND (cg I Interval between onset and death <br />PART I <br />I la) S. "I 4,\ S I 'e­ �-fU <br />DUE TO, AZ ral between onset and death <br />(b) I <br />DUE TO, OR AS A CONSEQUENCE OF: ry beNreen onset and death <br />(cl <br />OTHER SIGNIFICANT CONDITIONS - Co di6ons contributing to the death but riot related PART <br />PART PREGNANCY <br />Itl IF FEMALE. WAS THERE A 21. <br />9J THE PAST 3 MONTHS? <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />_ <br />II <br />(Aga <br />10 -541 Yes No <br />Yes No <br />Va No <br />26a. <br />29b. DATE OF IWURV /Ma.. Day Yr/ <br />26c. HOUR OF INJURY <br />HOW INJURY OCCURRED <br />Accident ❑ Undetermined <br />M <br />12m6d.[D*ESCRIBE <br />Suicide ❑ Pending <br />Homicide Investigation <br />26e. IWURV AT WORK <br />Yes ❑ NO ❑ <br />26f. PLAe E OFD at %(d _- farm. street lacbry <br />dfifiCC bitdi Y1. <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />-�- <br />27a. DATE OF DEATH (Md.. Day. Yr./ <br />28a. DATE SIGNED (MO.. Day. Yr.) <br />I cur. TIME OF DEATH <br />Sr <br />oI <br />\a__4 {__�_ <br />19,* <br />€ <br />M <br />27b. DATE SIGNED (Ald. Day. Yr.) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD (Mb.. Dry, Yr.) <br />28d. PRONOUNCED DEAD /Hour) <br />8 <br />, <br />, `�\ <br />I .VV M <br />Pii <br />$ <br />' c� 6 <br />M <br />27d. To the bat ol my cuffed a1 ,date and place due d ene <br />causels) saved. \ ^ a \n \ \d \ \\ <br />and Title V `� `t"' <br />280. On the basis of examination and /or i nvesugaron, in my opinion death occurred at <br />the lime. date and place and due to the cause(s) stated. <br />a and Title <br />29. DID TOBACCO <br />USE CON TO-THE DEATH <br />❑ YES ❑ UNKNOWN <br />3Qa HAS ORGAN OR TISSUE DONATION �BEE/N <br />❑ YES Pf1q <br />CONSIDERED? 30b <br />WAS CONSENT GRANTED? <br />❑ YES <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) /Type or Print/ <br />Dr. John J. Cannella, 729 N Custer. <br />DEC 2 <br />I <br />