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M -n i Z n M GO (n n 1 r c� rn c N N cn C,wz i-� WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, !T CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON F THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECT - }. THE LEGAL DEPOSITORY FOR VITAL RECORDS. C'> rr I C Tr z� --t -C O O 111 Z = M 3> 100 r ;:0 r- A CJ� 7C D► DATE OF ISSUANCE X./L4" 1� -.1711,w - "f v t F AI _ -- - S E P 12 2000 200204539 ASSISTANT STTRE LINCOLN, NEBRASKA HEALTH AND HUMAN SENW.4$ SY# STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES �CIr S(i PbRT' 7 VITAL STATISTICS r. _ - CERTIFICATE OF DEATH -= fo N O 0 N 0 s LIl W tO I DtCEOENT NAME FIRST MIDDLE LAST 2 SEX 3. OATEOFDEATH rMorTth Day Yearl Donald Lee Sander Male September 5, 2000 4 CITY AND STATE OF BIRTH Nl not in USA. name country) 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH iMonth Day Yearl Yes No (Yrs I 26c HOUR OF INJURY 5b MOS DAYS Sc . HOURS MINS Grand Island, Nebraska 68 -� M September 3, 1932 7 SOCIAL SECURTIY NUMBER 8a PLACE OF DEATH 506 -28 -0543 HOSPITAL ❑ Inpatient OTHER ❑ Nursinq Home ❑ ER Outpatient❑ Residence 8b FACILITY -Name /tfnot institution, give street and number) 724 S. Cleveland St. ❑ DOA ❑ Other tspecdv 8c CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island I Yes 0 No ❑ Hall 9a RESIDENCE - STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9d STREET AND NUMBER 0nc1,d,ngZpco68 8 e INSIDE CITY LIMITS Nebraska Hall Grand Island 724 S. Cleveland St. Yes No 10 RACE le.g , White Black American Indian 11 ANCESTRY (e g Italian, Mexican. German, etc) 12 MARRIED ❑ WIDOWED 13 NAME OF SPOUSE /it wire give maiden name) etc I ISoecilyl White (Speatyl American NEVER DIVORCED MARRI Carla Burton 14a USUAL OCCUPATION i&ve kind of work done during most 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specify only highest grade completed) Elementary or Secondary 10 121 College 11 -4 or 5 1 of working life. even if retired! w N z Owner/Operator Mower & Engine Service 4 Years _ _ 16 FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME John H. Sander Katherine E. Hinrich _ 18 WAS DECEASED EVER IN u S ARMED FORCES? 12-10-195219a INFORMANT-NAME (Yes no or unk I !It ves give war and dates of servicesl Yes jKorean Conflict 9 -9 -1954 Carla Sander i M n 1 M 1 190 IN h UH MAN I MAIL.INU AUUHtbb IJ I Htt I UH H.r U NU., 1.71 Y UH I UWN. J I A I t. L111'1 7.24 S. Cleveland St., Grand Island, Nebraska 68803 21711 - MBALMER - SIGNATURE 8 LICENSE NO 21a METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME gf_.Q-� o2u /(iL� x1143 ® Burial ❑ Removai I Sept. 8, 2000 lGrand Island City Cemetery i22a FUNERAL HOME NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston- Sondermann F.H. ❑Cremation 1:1 Donation Grand Island, Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.D NO CITY OR TOWN, STATE, ZIP) 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Ial (b). AND (c)1 Interval between onset and (leatn PART --k-' ' lal CEREBRAL ISCHEMIA 12 hrs DUE TO, OR AS A CONSEQUENCE OF b) METASTIC SARCOMA, SMALL BOWEL DUE TO OR AS A CONSEOUENCE OF Interval between onset and death _ 3 yrs. Interval between onset and dear) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL PART PREGNANCY 1 11 IN THE PAST 3 MONTHS' EXAMINER OR CORONERS (Ages 10 -541 Yes No Yes 7 No Yes No 2 26b DATE OF INJURY /Mo Day. Yr,) 26c HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED r Ac,:,denl ❑ Un(leler —ned -� M F-1 Su c de ❑ Pending 26e INJURY AT WORK 26f PLACE OF INJURY - At home, farm. street. lactory 26g LOCATION STREET OR R.F D NO CITY OR TOWN STATE. ❑ I ❑ ❑ i Homicide Invesl,yanon Yes No office building, etc /Specify) - j 27a DATE OF DEATH /Mo Day YrI 28a DATE SIGNED 1Mo Day Yr1 28b TIME OF DEATH Z SEPT. 5,2000 M -- oa _a- ¢ > 27b DATE SIGNED /Mo Day vr) 27c TIME OF DE 28c PRONOUNCED DEAD 1Mo Day. Yr I 28d PRONOUNCED DEAD /Hour) = r 0 as a gyp° 09/07/00 ;X 9:00 PM¢�� z M _ g,� w N z 27tl TO the best Of my knOwled a eath occurred at the bite. date a DI a and due t0 the - 28e On the basis of examination and or Investigation, in my opinion death occurred at ° cc 0 auselsi stated. U > the time. date and place and due to the cause(s) stated. ISi nature and Title, ► (Signature and Tillef ► 29 DID TOBACCO USE CONTRIB DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED 30.b WAS CONSENT GRANTED' J ❑ YES NO ❑ KNOWN C ❑ YES NO ❑ YES JT'N 3� 1 NAME AND ADDRESS OF CERTIFIER IPHYSICIA , CORONER S PHYSICIAN OR COUNTY ATTORNEYI ,Type or Print) - �X. DR. LARRY L. HANSEN 3016 W FAIDLEY AVE. GRAND ISLAND NE 68803 �� oG ic7oeo I 19h r)ATF F71 Fn RY RFrICTRAR /Mn 71av Yr I 11*1 SEP 11 2000 The South Thirty Two and Nine Tenths (32.9) feet of Lot Fourteen (14) and the North Fortv Five and Fight Tenths (45.8) feet of Lot Thirteen (13) , all in Block Twelve (12), in Parkhill Third Sub division, an Addition to the City of Grand Island, Hall County, Nebraska. C� I�)