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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES <br />SYSTEAf, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORQQNFILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISI~~~1'IpII.=-WHlCHIS <br /> <br />::~::~~::::~TORYFOR VITAL RECORDS. M~h;.'tiit~. <br />9/24/2004 200603 515 ",!~,v7JANL~~S. cdokER <br />A$SfsTAilicSTATE REGiBtRllR <br />LINCOLN, NEBRASKA HEAL TH ANt).HllMAN SERviCES SySTEM <br /> <br />- <br />STAlE OF NEBRASKA. DEPARTMENT OF HEALTII AND HUMAN SElt~ FiN~ ANp~RT <br />VITAL STATISTICS ..-=_;- - <br />CERTIFICATE OF DEATH <br /> <br />4. CITY AND $T A TI:: OF BIRTH (11"01" U.S.A.. "am. coumry) <br /> <br />Sa. AGE - L.ast Birthday <br />IYrs.1 <br />63 <br /> <br />UNDER 1 YEAR <br />5b. MOS. I DAYS <br />I <br /> <br /> <br />Female <br /> <br />September 21, 2004 <br />6. DATE: OF BIATH (Month, DiW Year) <br /> <br />1. DECEDENT. NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />2. SEX <br /> <br />Leota <br /> <br />Anne <br /> <br />Sanders <br /> <br />Latrobe, Pennsylvania <br />7. SOCIAL SECURTIY NUMBER <br /> <br />January 15, 1941 <br /> <br />123-32-6516 <br /> <br /> aa. PLACE OF DEATH <br /> HOSPITAL: 0 Inpatient <br /> D E.R Outpatient <br /> 0 DOA <br />ad. INSIDE CITY LIMITS <br /> <br />OTHE.I~: 0 NurSing Home <br />,[] ResIdence <br /> <br />o 01her (SfJecdvl <br /> <br />8b. FACILITY. Name (If not institution, giVB streel atld (lumber) <br /> <br />Home: 2205 Riverside Drive <br /> <br />10, RACE - (e,g., White. Black, American Indian. <br />etc.) (Specify) <br /> <br /> <br />9d. STREI::T AND NUMBER (Inalvolng Zip COdel <br /> <br />ge INSIDE CITY LIMITS <br /> <br />Eic.'-CITV:"TOWN OFII.OCATION OF D~rH <br /> <br />Grand Island <br /> <br />9a. RESIDENCE. STATE <br /> <br />Nebraska <br /> <br />Yes [Xl No 0 <br /> <br />13. NAME OF SPOUSE (II wtfe. give m(iiden namej <br /> <br />White <br /> <br />Rans Sanders <br /> <br />. 16. <br /> <br />MIDDLE <br /> <br />LAST <br /> <br /> <br />15. EDUCATION (Specify only highest grade completed) <br />Elemen1ary or Secondary 10.12) College [1-.4 or S"I <br />12 <br /> <br />14a. <br /> <br />MOTHER <br /> <br />MIDDLE <br /> <br />MAIDEN SURNAME <br /> <br />James R. Pauline <br /> <br />, 16. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />(Yes. no. or unk.) III yes. give war and dates of services) <br />No Rans Sanders <br /> <br />19b. INFORMANT MAILING ADD~ESS ISTREET OR A.F.D. NO.. CITY OR TOWN. STATE ZIP) <br /> <br />Beiver <br /> <br />2205 Riverside Drive, <br /> <br />20. EMBALMER - SIGNATURE & LICENSE NO. <br /> <br />Grand Island, NE <br /> <br />68801 <br /> <br />21a. METHOD OF DISPOSITION 21b. DATE <br /> <br />21 c. CEMI::TERY OR CREMATORY NAME <br /> <br />Not Embalmed <br />22a. FUNERAL HOME - NAME <br /> <br />o Burial 0 Ramo..1 Sept. 21, 2004 Westlawn Memorial Crematory <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br /> <br />Apfel-Butler-Geddes <br /> <br />~ Cremation 0 DOnahon <br /> <br />Grand Island, NE <br /> <br />22b. FUNERAL HOME ADDRESS <br /> <br />(STREET OR R.F.D. NO. CITY OR TOWN. STATE, ZIP) <br /> <br />1123 West Second, Grand Island, NE. 68801 <br />23. IMMEDIATE CAuSE IENTER ONLY ONE CAUSE pER LINE FOR lal.lbl. AND lell <br />PARr r \ <br />r 1"1 A.Cl(\Ot.ty~q..~" "y"\. 'i <br />DUEY6;oRAs"A CONSEQUENCE OF.--- --- . <br /> <br />Ibl "'''''''(\:::>\~~ \.:::. \~ <br />DUE TO. OR AS A CONSEOUENCE OF: <br /> <br />Interval between onset and deatn <br /> <br />l.Q nO <br /> <br />Interval between onsel and death <br /> <br />~r"\.G <br /> <br />Inte(val between onset and deatn <br /> <br />lei <br />~AFlT OTHER SIGNIFICANT CONDITIONS. Conditions contribu~nQ to the death but not related <br /> <br />II <br /> <br /> <br />26c. HOUR OF INJURY <br /> <br />26a. 2Gb. DATE OF INJURY <br />0 AcCident 0 Undel$rmined <br />0 Sl,Ilcide 0 Perichng 260. INJURY AT WORK <br />0 Homicide Investigation YesD NoD <br /> <br />2aa. DATE SIGNED (MD.. Day. Yr.1 <br /> <br />2ab, TIME OF DEATH <br /> <br />- 1>" <br />i~g <br />:!~ ~ <br />. 8 8'0 <br />: Z 'E <br />i ,'! ~ <br /> <br />z>- <br /> <br />ll>~ ~ <br />II;;:>- <br />~g~ <br />llza <br />,'!ii/u <br />8 " <br /> <br />M <br /> <br />260. PRONOUNCED DEAD (MD.. Day. Yr) <br /> <br />2ad. PRONOUNCED DEAD (HQur/ <br /> <br />M <br /> <br />M <br /> <br />28e. On the basis of examination and'or investigation, in my opinion death occurred at <br />tne lime. date and place and due to the cause(sl stat8d. <br /> <br />NO <br /> <br />30.b WAS CONSENT GRANTED? <br />DYES <br /> <br />G-'NO <br /> <br />29. <br /> <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER.S PHYSICIAN OR COUNTY ATTORNEYI (Type DI' Print) <br /> <br />Jennifer King <br />32a. REGISTRAR <br /> <br />M.D. <br /> <br /> <br />Grand Island. NE <br /> <br />68803 <br /> <br />32b. DATE FILED BY REGISTRAR (MD.. Day. Yr-! <br /> <br />SEP 2 3 2004 <br />