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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS-NAME (First, Middle, Last, Suffix) Leonard Andrew Stade 2. SEX Male " 3. DATE OF DEATH (Mo., Day, Yr.) December 26, 2009 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Southern Buffalo County, Nebraska 5a. AGE - Last Birthday (Yrs.) 86 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) February 7, 1923 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -44 -5132 8b. FACILITY -NAME (If not Institution, give street and number) Gibbon Good Samaritan Center 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Gibbon 68840 8d. COUNTY OF DEATH I Buffalo 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Buffalo 9c. CITY OR TOWN Shelton 9d. STREET AND NUMBER 56030 Denman Rd 9e. APT. NO. I 9f. ZIP CODE 68876 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Mildred Irene Jorgensen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred Stade 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mary Pauline Kroll 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Mildred Irene Stade 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Mark McBride 16b. LICENSE NO. 1199 16c. DATE (Mo., Day, Yr.) December 30, 2009 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Liberty Cemetery Kearney County Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Horner Lieske McBride & Kuhl Funeral and Cremation, 2421 Avenue A, Box 777, Kearney, Nebraska 17b. Zip Code 68848 CAUSE OF DEATH (See instructions and examples) ,. To be completed by: CERTIFIER 18. PART I. Enter the chain of events -- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Immediate respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMFDIATE CAUSE (Final a) Cardio pulmonary Arrest disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Hypertension any, leading to me cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Dementia (disease or injury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant time of death at oeat P ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 0 Investigation ❑ Suicide ❑ Could determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE B W I. r E z 23a. DATE OF DEATH (Mo., Day, Yr.) December 26, 2009 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) December 28, 2009 23c. TIME OF DEATH 09:30 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 er 0 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) a El 2 Gerald I. Jensen, MD 24e. On the basis of examination and/or Investig tion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, HYS1CIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A Gerald I. Jensen, MD, 3907 6th Avenue, Kearney, Nebraska, 68845 TORNEY) (Type or Print) 128a. REGISTRAR'S SIGNATURE J 6 - ' 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I December 30, 2009 STATE OF NEBRASKA 0 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN1YHUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA'DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR' VITAL R €GOR:D5,t ,. DATE OF ISSUANCE 01/05/2010 LINCOLN, NEBRASKA ti0120982 TJVLEY £'9 )'17 A'XSISTAMT S747E REGISTRAR DEPARTMENT OF HEALTH AND HL 1* SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERWGES CERTIFICATE OF DEATH 09 03066