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<br />
<br />-.-""J!!
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />
<br />::;;::~::::::~TORY FOR VITAL RECORDS. ~:):I~~ I:
<br />JUl 0 8 2008 20090 10 19 ' "'$S~T;~:;~g1~~ J,>
<br />LINCOLN, NEBRASKA HEIU:.TIf AND HUMAN SERVIOES "
<br />,-. (:1 r" a I . '" ,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAqSRVIEl:' - _ :~.: '
<br />TIFICATE F ' :~'.
<br />
<br />1. DECEDENrS-NAME (Flrsl, MI<I<lI., L..I, Suffix)
<br />
<br />
<br />Reuel Gaylord Andersen
<br />4, CITY AND STATE OR TERRITORV, OR FOREIGN COUNTRV OF BIRTH
<br />
<br />~S " ", .......
<br />Mal~>0"'~
<br />
<br />s.. AGE-L..I Blrthd.y Sb. UNDER 1 VEAR So. UNI\'ER
<br />(Vrs.) MOS. DAYS HOURS
<br />
<br />Harlan, Iowa
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />82
<br />
<br />S.. PLACE OF DEATH
<br />~ IEIlnp.lI.nl
<br />O'&AIOulpellenl
<br />o DOA
<br />
<br />~ 0 Nursing Hom./L TC
<br />o Doco<lonl'o Homo
<br />o Olh.r(Sp.clfy)
<br />
<br />o Hooplc. F.clllly
<br />
<br />479-26-6328
<br />
<br />8b. FACILlTY-NAME (II nolln.lltutlon, glv. .treel .n<l numb.r)
<br />
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<br />
<br />Good Samaritan Health Systems
<br />Bc. CITY OR TOWN OF DEATH (Inclu<leZlp Co<l.)
<br />Kearne 68848
<br />
<br />
<br />68803
<br />
<br />B<I, COUNTY OF DEATH
<br />Buffalo
<br />
<br />9a. RESIDENCE-STATE Db. COUNTY
<br />
<br />Hall
<br />
<br />Nebraska
<br />9<1. STREET AND NUMBER
<br />
<br />2456 LaMar Ave.
<br />
<br />91. ZIP CODE
<br />
<br />9g, INSIDE CITY LIMITS
<br />IKI v.. 0 No
<br />
<br />10.. MARITAL STATUS AT TIME OF DEATH 00 MarTI.<I 0 N.v.r M.rTlod lab. NAME OF SPOUSE (Flrsl, Middlo, Lal'. Suffix) II wlf., glv. m.ldon n.me.
<br />
<br />
<br />o MarTI.<I. but..p.r.l.d 0 Wldowe<l 0 Dlvorc.<I 0 Unknown
<br />
<br />
<br />11. FATHER'S-NAME (First, Middle, L..~ Suffix)
<br />
<br />12. MOTHER'S"NAME (Flrsl, Middle, Mal<len Sum.m.)
<br />
<br />Ida
<br />
<br />Pedersen
<br />
<br />John
<br />
<br />Andersen
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />13. EVER IN U.s. ARMED FORCES1 Glvo dete. of le",lceIlVe..
<br />
<br />(Vo., No, or Unk.) Yes
<br />
<br />1S. METHOD OF DISPOSITION
<br />[JIBurt.1 ODonatlon
<br />
<br />Dcremltlon OEn10mbment
<br />o Removal DOtntr(sptelM
<br />
<br />Wife
<br />
<br />19c. DATE (Mo., D.y, Yr.)
<br />
<br />1Gb. LICENSE NO,
<br />
<br />1.59' /
<br />
<br />June 21, 2008
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />Grand Island City Cemetery
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Slroo~ Clly or Town, SI.I.)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Coda
<br />68801
<br />
<br />CAUSE OF DEATH See instructions and exam
<br />
<br />
<br />'1. PART I. Enter the clullli of IIwrlt:J _ dlana.., l"'u'I*., (lr lCampllcatlon.~ thlll dlrwdly c;;.\IMd tn. c:I..t... DO NoT IIInllllr tenolnel .vtlntt ..ucn .s e411r~1..e: .m.lt
<br />....plr.I(l1'Y .rnt.1, or vlllnttltulat fibrillation wltho.... IIhpwlng lhtt .tloloiY. DO NOT ABBREVIATE. Enler only on. ~u.. On IlIn.. A~d .ddlllonallln.. If n.c;;.....r'y.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />I on"llo d80th
<br />I
<br />I
<br />
<br />IMMEDIATE CAUSE (Flnel
<br />dleea.e or condition ....ultlng
<br />In d..lh)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />C~~~
<br />
<br />DUE TO, OR AS A CONSEQUENCE 0 :
<br />
<br />~~
<br />
<br />
<br />)- It,\L-!.T
<br />
<br />
<br />
<br />.)
<br />
<br />L:"'fvv
<br />
<br />Sequendally list condition.. If b)
<br />any, I..dlng to the cause listed
<br />on IIn. a.
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />~Pu
<br />
<br />"
<br />
<br />
<br />c'
<br />~
<br />
<br />Enter ,il. UNDERLYING CAUSE 0)
<br />(dl..... or Injury "'.llnlll.l.d
<br />the evonl. rolulllng In <I..lh) DUE TO. OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />on.el to doalh
<br />I
<br />I /1 tfctc; 5
<br />
<br />d)
<br />
<br />fA
<br />
<br />lB. .PART II. OTHER SIGNIFICANT CONDITIONS.Con<llllon. contr1butlng 10 Iho dealh bu' not re.ulllng In Ihe undorlylng C.U" glv.n In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES )l(NO
<br />
<br />210. WAS AN AUTOPSY PERFORMED1
<br />
<br />o VES 'J&tNO
<br />
<br />21<1, WERE AUTOPSV FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />
<br />oVES oNO
<br />
<br />II::
<br />w
<br />Ii:
<br />ffi
<br />u
<br />~
<br />~
<br />Q.
<br />g
<br />U
<br />'II
<br />lD
<br />{!.
<br />
<br />1r.J-t.. 'a.J
<br />
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />o Drlv.r/Operetor
<br />o Pa..enger
<br />o P.d..lrlan
<br />o O"'.r (Sp.clfy)
<br />
<br />, ...--
<br />~- c...ca-
<br />
<br />
<br />20. IF FEMALE:
<br />o Not prognenl wllhln pool y..r
<br />o progn.nl .t 11m. of d..lh
<br />o Not pregnantl but pregnant within 42 days of d.ath
<br />o Not pregnant. but pregnant 43 day. to 1 year before death
<br />oUnknown If pr.gn.nl wllhln the p..1 year
<br />
<br />21a. MANNER OF DEATH
<br />o N~al 0 Homlcld.
<br />~cldent 0 P.ndlng Inve8tlgatlon
<br />o Sulcl<le 0 Could not bo dotermlned
<br />
<br />
<br />220. PLACE OF INJURV ~rm, ""OOt, faclory, offic. building, conltrucllon .11., .10. (Speolfy)
<br />
<br />kelA 4'L
<br />
<br />CITYITOWN
<br />
<br />Gtand. +'5"!4Y1d
<br />
<br />ZIP CODE
<br />
<br />STATE
<br />vtJ
<br />
<br />22f. LOCATION OF INJURY - STREET & NUMBER, A
<br />
<br />~ 451,:: L..a.l'hat !tl)f',
<br />
<br />tv lfW3
<br />
<br />~~
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<br />~~
<br />
<br />23.. DATE OF DEATH (Mo., D.y, Yr.)
<br />June 17, 2008
<br />
<br />24.. DATE SIGNED (Mo., Day, Vr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />:>.~iU
<br />'" UZ
<br />-..:
<br />'lil"'o
<br />i: ?i I: >-
<br />"iio..o(..J
<br />e "'~ z
<br />oil: 0
<br />u..,
<br />! Z:J
<br />000
<br />I- !~
<br />uo
<br />
<br />m
<br />
<br />
<br />23b. DATE SIGNED (Mo.. D.y, Vr.)
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Vr.) 24<1. TIME PRONOUNCED DEAD
<br />
<br />
<br />I
<br />L
<br />
<br />e best of my knowledge, death occLuTed at the time, date and pl.c.
<br />u. to Iho cau.e(l) lla"'d.(SI~ and Title)
<br />
<br />
<br />. >~
<br />
<br />m
<br />
<br />m
<br />
<br />24e. On the basis of eXBmlnatlon and/or Investigation. in my opinion death occurred
<br />Bt the time, date and place and due to the Ciluse(s) stat.d. (Signature and Title)
<br />
<br />
<br />2Gb. WAB CONSENT GRANTED?
<br />Not Appllc.bl. If 26.1. NO 0 VES 0 NO
<br />
<br />2&.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED1
<br />o VES g....,rO
<br />
<br />2S. DID TOBACCO ~ONTRIBUTE TO THE DEATH1
<br />DYES [31'r0 0 PROBABLY 0 UNKNOWN
<br />
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Prlntl
<br />Ramon Salumbides, M.D., 3219 Central Ave., Ste. 107, Kearney, Nebraska 68847
<br />
<br />2Bo. REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Gb. DATE FILED BY REGISTRAR (Mo., Day, Vr.)
<br />
<br />JUL S 2008
<br />
<br />
<br />Exhibit
<br />
<br />"A"
<br />
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