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<br />Phelps County, Nebraska
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<br />Wis
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<br />98. PUKE OF DEATH
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<br />IN
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<br />Hall
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<br />A
<br />cv ..................
<br />12. MAtRIEUNEVER MARRIED.
<br />13. NAME OF SPOUSE (N wife, glee maiden name)
<br />U
<br />t13 ........................
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<br />White
<br />F...................
<br />Marrie$
<br />aD ............ ......�.
<br />14a, USUAL OCCUPATION {Give kind of won' done dumV most -
<br />D OF BUSINESS INOIISTRY
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<br />�..................
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<br />7Building
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<br />Unknow n
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />I7. MOT R - MAICWN NAME FIRST MIDDLE LAST
<br />Frank NMN Anderson
<br />hannah NMN Lan uist
<br />18. WAS DECEASED EVER W U.S. ARMED FORCES?
<br />]9 INFORMANT NAME - +VLR4G ADDRESS ISTREET OR R.F.D NO.. CITY OR TOWN, STATE. ZIPI L O q
<br />688
<br />(res. rn of VA.) fN Yes. Dire war and dates dt services!
<br />4v
<br />No - - - - - --
<br />Grace Ander on 1503 St. Paul Rd. , Grand Island Ne
<br />2ft BURIAL, Crelnanbn,Removal,
<br />20b DATE
<br />20c. CEMETERY OR CREMATORY -NAME
<br />a�
<br />LOCATION CITY OR TOWN STATE
<br />w
<br />.o
<br />Burial
<br />Nov. 21 1989
<br />Westlawn Memorial
<br />_
<br />Grand Island Nebraska
<br />5J
<br />21- EM8 - SIGNATURE d LI ENSE NO.
<br />22. FUNERAL HOME - N.1ME AND
<br />DRESS ISTREET OR R-F -D. NO -, CITY OR TOWN, STATE. ZIPI 68861
<br />,?
<br />Livin stop -So dermann
<br />505 West Koenig, Grand Island, N
<br />I Inlerval between onset and death
<br />23. *AMEDLA7E CAUSE I (ENTER ONLY ONE CAUSE PER LINE FOR le +. tai. AND I }
<br />18I
<br />DL/E TO, OR AS A CONSEOUENCE OF: .�� I Interval betty ousel and death
<br />I
<br />fbi
<br />DUE TO. OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />f
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<br />n;
<br />PREGNANCY IN THE PAST 3 MONTHS? (Spec Yes or ft) EXAMINER OR C.ORGNE
<br />Yes D No ❑ ,� (Specify Yes or NO) G
<br />Cll
<br />DATE OF INJURY jhta Day. Yr.J
<br />C/)
<br />CERTIFICATE OF DEATH
<br />SEE INSTRUCTION
<br />v
<br />MANUAL
<br />Earl Milford Anderson
<br />Male
<br />Place ................
<br />0
<br />NSC ............... ..
<br />$
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<br />...................
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<br />to
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<br />x
<br />d
<br />• IYrs.I
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<br />A.....................
<br />U_
<br />Phelps County, Nebraska
<br />F- N
<br />Wis
<br />.......................
<br />n�
<br />98. PUKE OF DEATH
<br />W U
<br />HOSPITAL: 0 Inpaimnt D ERrOutpavent D DOA
<br />L)
<br />W a
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<br />Sc. CRY, TOWN OR LOCATION OF DEATH
<br />o�
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<br />9e. D�Edy ya LIMIT S
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<br />IN
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<br />Hall
<br />N
<br />0
<br />Yes
<br />.
<br />10- RACE - le.¢, f Wft Stack, American Indian,
<br />cv ..................
<br />12. MAtRIEUNEVER MARRIED.
<br />13. NAME OF SPOUSE (N wife, glee maiden name)
<br />.
<br />t13 ........................
<br />(Sipes W -
<br />I
<br />F
<br />i..
<br />White
<br />F...................
<br />Marrie$
<br />aD ............ ......�.
<br />14a, USUAL OCCUPATION {Give kind of won' done dumV most -
<br />D OF BUSINESS INOIISTRY
<br />. .....................�:..
<br />Elenwla a Seconds 0.12 1 ,Cot
<br />Secondary l Iege 11 -4 a s.!
<br />�..................
<br />ii
<br />7Building
<br />0 .....................
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<br />U_
<br />CERTIFICATE OF DEATH
<br />3
<br />Census Tract No.
<br />{3
<br />Rev- 3.'68 1+
<br />.. �.,.-- t.,,-, uti..r., ..--o-n - - - r r ran. --t r!Dw m -_7
<br />W,O/ l -0 y 24IN &IC m b 61144&b / s e-/M- b fvF
<br />>TRAR 132b. DATE FRED BY REG45TRAS Wo., Day. Yr.)
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. sex
<br />3- DATE OF DEATH (M". Day. Year)
<br />Earl Milford Anderson
<br />Male
<br />November 17, 1989
<br />4. CITY AND STATE OF BIRTH (O nor M U. S.A, name country)
<br />Sa. AGE - Last INr8tday
<br />UNDER I YEAR
<br />r, . DATE OF BIRTH (Mont,, Day. Year)
<br />Sb. MOS DAYS
<br />Sc HWRa MINS.
<br />• IYrs.I
<br />1
<br />Phelps County, Nebraska
<br />83
<br />June 26, 1906
<br />7. SOCIAL SECURITY NUMBER
<br />98. PUKE OF DEATH
<br />HOSPITAL: 0 Inpaimnt D ERrOutpavent D DOA
<br />507 -14 -8370
<br />OTHER : D Nursing Home x nes a"Ine D Other (Specify)
<br />Bb. FACILITY - Name (d nor hstirufroA glee sneer arid number)
<br />Sc. CRY, TOWN OR LOCATION OF DEATH
<br />6d. INSIDE CITY LIMITS 8e COUNTY OF DEATH
<br />(Specify Yes or No;
<br />I I
<br />1503 St. Paul Rd.
<br />Grand Island
<br />Yes Hall
<br />9a RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CTfY, TOWN OR LOC4TION 9d. STREET AND NUMBER fftkd rV Zia 0188 Q 1
<br />9e. D�Edy ya LIMIT S
<br />IN
<br />I
<br />Nebraska
<br />Hall
<br />Grand Isl=and 1503 St. Paul Rd.
<br />Yes
<br />10- RACE - le.¢, f Wft Stack, American Indian,
<br />11- ANCESTRY le.g.pakan. Mexican. German, etc.)
<br />12. MAtRIEUNEVER MARRIED.
<br />13. NAME OF SPOUSE (N wife, glee maiden name)
<br />.
<br />etc _I ISCscfy)
<br />(Sipes W -
<br />I
<br />[ MODINED. DIYORCED fe cily)
<br />White
<br />American
<br />Marrie$
<br />Grace Casper
<br />14a, USUAL OCCUPATION {Give kind of won' done dumV most -
<br />D OF BUSINESS INOIISTRY
<br />Elenwla a Seconds 0.12 1 ,Cot
<br />Secondary l Iege 11 -4 a s.!
<br />of working fee, even dreB'rw
<br />ii
<br />7Building
<br />Car enter
<br />f
<br />I `!
<br />Unknow n
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />I7. MOT R - MAICWN NAME FIRST MIDDLE LAST
<br />Frank NMN Anderson
<br />hannah NMN Lan uist
<br />18. WAS DECEASED EVER W U.S. ARMED FORCES?
<br />]9 INFORMANT NAME - +VLR4G ADDRESS ISTREET OR R.F.D NO.. CITY OR TOWN, STATE. ZIPI L O q
<br />688
<br />(res. rn of VA.) fN Yes. Dire war and dates dt services!
<br />No - - - - - --
<br />Grace Ander on 1503 St. Paul Rd. , Grand Island Ne
<br />2ft BURIAL, Crelnanbn,Removal,
<br />20b DATE
<br />20c. CEMETERY OR CREMATORY -NAME
<br />Md.
<br />LOCATION CITY OR TOWN STATE
<br />Donation
<br />Burial
<br />Nov. 21 1989
<br />Westlawn Memorial
<br />Park
<br />Grand Island Nebraska
<br />21- EM8 - SIGNATURE d LI ENSE NO.
<br />22. FUNERAL HOME - N.1ME AND
<br />DRESS ISTREET OR R-F -D. NO -, CITY OR TOWN, STATE. ZIPI 68861
<br />,?
<br />Livin stop -So dermann
<br />505 West Koenig, Grand Island, N
<br />I Inlerval between onset and death
<br />23. *AMEDLA7E CAUSE I (ENTER ONLY ONE CAUSE PER LINE FOR le +. tai. AND I }
<br />18I
<br />DL/E TO, OR AS A CONSEOUENCE OF: .�� I Interval betty ousel and death
<br />I
<br />fbi
<br />DUE TO. OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />f
<br />I
<br />f'
<br />PART SIGNIFICANT C.ONDRIONS - Conditions conbibdmg Io death but not Wailed PART IM IF FEMALE. WAS THERE A 24. AUTOPSY 25- WAS CASE REFERRED T MEDICAL
<br />PREGNANCY IN THE PAST 3 MONTHS? (Spec Yes or ft) EXAMINER OR C.ORGNE
<br />Yes D No ❑ ,� (Specify Yes or NO) G
<br />26a. ACCIDENT, SINCIDE, HOMICIDE. UNDET.,
<br />DATE OF INJURY jhta Day. Yr.J
<br />26c. HOUR OF INJURY 266 DESCRIBE HOW INJURY DCCU REO
<br />126b.
<br />OR PEND9NG INVESTIGAT" (Specfyy)
<br />26e. INJURY AT WORK
<br />261. PLACE OF INJURY - Al home- farm. Steel. factory,
<br />2&7 LOyATP0N STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />j5pecfy Yes aNdJ
<br />. office building, etc. (SpecdyJ
<br />278. DATE OF DEATH Wo Day, Yr. •
<br />28a. DATE SIGNED (Mo.. Day, Yr.)
<br />28b. 'TIME OF DEATH
<br />/V
<br />27b. jDATE SIGHED (kW., Day, Yy
<br />- NBt --LL
<br />27c. TIME OF DEATH
<br />26c. PRONOUNCED DEAD o, Dey Y, I
<br />26d. PRONOUNCED DEAD (Hwrr
<br />�
<br />e27d.
<br />o
<br />70 one bear M my death umed ti d to M place and due 1b ttte
<br />28e. On the basis of exammatbn and -on imeshgacon, in my opinion death omvrred at
<br />}reause{sl pared
<br />s
<br />ft time date and Nice and due to" causelsf gated.
<br />( re and Tek Y
<br />I
<br />fSi nature and Title
<br />290. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 3Da. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30b
<br />WAS CONSENT GRANTED?
<br />� Y , 0 YES NO ❑ UNKNOWN JC- C YES - ND
<br />ii YES NO
<br />3
<br />Census Tract No.
<br />{3
<br />Rev- 3.'68 1+
<br />.. �.,.-- t.,,-, uti..r., ..--o-n - - - r r ran. --t r!Dw m -_7
<br />W,O/ l -0 y 24IN &IC m b 61144&b / s e-/M- b fvF
<br />>TRAR 132b. DATE FRED BY REG45TRAS Wo., Day. Yr.)
<br />
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