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<br />WHEN THIS Copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES <br />SYSTEM, "' CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REc;..Q80_01l FIL.EWlTH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSJ}P&~J;f!eN-.:V/fIlCHIS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~'/"~.~~:'~.~l2f!-~__i ' <br />DATE OF ISSUANCE .. - ttJ._~ <br />10/12/2004 200810364 ;;r .., ~NLEYS. (;Qo~ff · <br />LINCOLN, NEBRASKA HEALTH At~~=~==..(; <br />~}-~ : ~'~ ','.. "S"'~ .,~~(:.~ ' '~~." '~'..:~./;, ~.~~ ' '.:, .' <br />STATE OF NEBRASKA- DEPARlMENT OF HEALTII AND HUMAN S~~~'~~~-SujtPoRT <br />CERTI~~S;~~;~EATH'~'-""~"~~\ -"F~'~ ~.~ 04 08251 <br /> <br />83 <br /> <br />UNDER 1 YEAR <br />5b. MOS. I DA VS <br />I <br /> <br /> <br />3. DATE OF DEATH IMonth. Day. YeM <br /> <br />July 21, 2004 <br /> <br />1. DECEDENT.. NAME <br /> <br />FIRST <br /> <br />MIODLe <br /> <br />LAST <br /> <br />Eugene <br /> <br />Euclid <br /> <br />Andersen <br /> <br />4. CITY AND STATE OF BIRTH (If nol in U.S.A.. name CO""try) <br />Norman, Ne. <br /> <br />Sa. AGE. Last Birthdav <br />(Yrs.l <br /> <br />6. DATE OF BIRTH IMonth. Day. Year) <br /> <br />Aug. 11, 1920 <br /> <br />7. SOCIAL SeCURTlV NUMBER <br /> <br />8b. FACILITY. Namo <br /> <br />(If not insMution, give Str8St and nl,/mber) <br /> <br />8a. PLACE OF DeATH <br />HOSPITAL: 0 Inpatient <br />o ER Outpatient <br />o DOA <br /> <br />OTHeR. ~ Nursing HOmE! <br /> 0 Re$II:lenct! <br /> 0 QIMr {Sf)eCJ!vJ <br /> <br />506-18-1330 <br /> <br />Madonna Care Center <br />00. CITV TOWN OR LOCATION QF"DEATH <br /> <br />80. IN SlOE CITY LIMITS 8e. COUNrnJF DeATH <br /> <br />10. RACE. (e.g., White. Black. American Indian. <br />elc.IISDeClfylWh i t e <br /> <br />11. ANCESTRY fe,g.. Italian, Me)(jcan. German. atcl <br />fSpeclfy! Swedish/Denmark <br /> <br /> <br />Sd. STREET AND NUMBER line/wing Zio Code{ <br /> <br />Se. INSIDE CITY LIMITS <br /> <br />Lincoln <br /> <br />Nebr. <br /> <br /> <br />He;ll., <br /> <br />Greenwich ve. ~ No D <br />13, NAME OF SPOUSE (If w/le, give msi(ien name) <br /> <br />Sa. RESIDENCE - STATE <br /> <br />Dorrene O. Maineeke <br /> <br />148. USUAl. OCCUPATION (Give kindofwor/( don8 dunng most <br />of wor/(yJ$/ite. even)1 reltired) <br />~onstruction Electrician <br /> <br />Commonwealth Electric <br /> <br />15. EDUCATION (Specify only nighest grade completed) <br />Elementary or~Ondary' (0.121 College /1.4 or 5+\ <br /> <br />Leonard <br /> <br />C. <br /> <br />MIDDLE LAST <br />^ A~dersen <br />.LR e:reeB. <br /> <br /> <br />17, MOTHER <br /> <br />MIDDLE <br /> <br />MAIDEN SURNAME <br /> <br />16. FATHER. NAME <br /> <br />FIRST <br /> <br />Ruth <br /> <br />Bergsten <br /> <br />18. WAS DECeASED EVER IN U.S. ARMED FORceS? <br /> <br />Ive" nO'ye~ ["MY" r-df"i ~'4"'i711l- 21- 45 <br /> <br />Dorrene O. Andersen <br /> <br />19b. INFORMANT <br /> <br />MAILING ADDRESS <br /> <br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATe. ZIP) <br /> <br />1144 50'_ Greenwich <br /> <br />Grand Island. Ne.,68801 <br /> <br />20. EMBALMER. SIGNATURE & LICENSE NO. <br /> <br />L -r~c B~ ~/52- <br /> <br />21 a. METHOD OF DISPOSITION <br /> <br />21b, DATE <br /> <br />21e. CeMeTeRY OR CReMATORV NAME <br /> <br />[!] Burial 0 Removal <br /> <br />7-26-04 Westlawn Memorial Park <br />21d. CEMETERY OR CREMATORV LOCATION CITV OR TOWN STATE <br /> <br />na. FUNERAL HOME - NAME <br /> <br />Apfel~Butler-Ge~des <br /> <br />o Cremation 0 C1onahon <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 <br /> <br />Grand Island, Ne. 68801 <br /> <br />23. IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR lal. fbi, AND (ell <br />PART n (\ \ <br />I lal KeSp' rare\[ ~. 1~ '- \11l't-. <br />Ib~UE TO, OR AS f C~~~ENC~1\ \ <br /> <br />DUE TO, 0 AS A CONSEOUENCE OF. <br /> <br />Interval betWeen Onset qnd dealh <br /> <br />Interval between onset and oealtl <br /> <br /> <br />i\C1.c <br /> <br />Interval between onset and deatn <br /> <br />lei <br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the cleath but not related <br /> <br />II <br /> <br />260. <br />D Accident D Undetermined <br />D SI,Jlcide D pending <br />D Homicide Invesllgation <br /> <br />26b. DATE OF INJURY IMo" Day, Yr.) 26c. HOUR OF INJURY <br /> <br /> <br />28a. DATe SIGNED IMo.. Day. Yr.{ <br /> <br />28b TIME OF DEATH <br /> <br />260. INJURY AT WORK <br /> <br />Yo. 0 No ~ <br /> <br />27a, DATE OF DeATH IMo" Day. Yr.! <br /> <br />JUly 21,2004 <br /> <br /> <br />M <br /> <br />: E1~ <br />!!~>- <br />~I", <br />= 8 2-15 <br />:q <br />i ~ <br />I <br /> <br />27b. DATE SIGNED IMo.. Day. Yr.! <br /> <br />27c. TIME OF DeATH <br /> <br />2Sc. PRONOUNCeD DeAD lMo.. Day, Yr.! <br /> <br />28d, PRONOUNCEO DeAD (Hour{ <br /> <br />July 23,2004 <br /> <br />M <br /> <br />27d. ro lhe best of my knowledge <br />causelsl stated. <br /> <br />28e, On tile basis of examination and'Ot InvElstigation.ln my opinion death occurred at <br />the time. datll!!l and place and due to the cause/s) stated. <br /> <br />____ I ..IS'9~'!'~ca and 1111~U!':".. ____ _. <br />2S. DID TOBACCO USE CONTRIBUTE TOp DelTA? . <br />DYES g Ni/" D UNKNOWN ~.. NO <br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONeR'S PHYSICIAN OR COUNTY ATTORNEYJ Iry"" or Pllnl! <br /> <br />30.b WAS CONSENT GRANTED? <br />o YES ~O <br /> <br />Jason,Potts,M.D. <br /> <br />3901 Pine Lake Road Ste. 220 Lincoln,Nebraska 68516 <br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) <br />JUL 2 8 2004 <br /> <br /> <br />32a. REGISTRAR <br />