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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ara Elizabeth Ranslem 2. SEX , , , , , : Female •3. DAIt OF'DEATH (Mo., Day, Yr.) , Mara r5, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Inland, Nebraska 5a. AGE - Last Birthday (Yrs.) 91 5b. UNDER 1 YEAR 5c. UNDER 1 DAY , 6. DATE OF BIRTH (Mo., Day, Yr.) December 12, 1922 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -14 -6591 8b. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care 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) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 1311 N. Cedar Street re. APT. NO. 9f. ZIP CODE I 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Marled ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Malcolm Lee Ranslem 11. FATHER'S -NAME (First, Middle, Last, Suffix) Leonard Schuman 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ethel Pearl Stroops 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Malcolm Lee Ranslem 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation [] Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) March 10, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART 1. 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 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: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting onset to death < 1 Week In death( DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b)Acute Myocardial Infarction 1 < 1 Week any, leading to the cause listed I on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated . the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) I I I 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. Diabetes 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death ❑ 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 ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be detemlined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator 0 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 Z 5 i a r tJz 23a. DATE OF DEATH (Mo., Day, Yr.) March 5, 2014 z, g t 11 ,. ac Y W , 2 z 0 8 U ~ ti s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) March6,2014 23c. TIME OF DEATH 12:25 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD O 3d. To the best of my knowledge, death occurred at the time, date and place 2 C and due to the cause(s) stated. (Signature nd Title) 2 Jennifer L. Brown, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Tale) 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 (Type or Print Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE d i - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 7, 2014 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKAAEfA,RTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL d R $. 201408026 C • A SSISTA7VT STATE Re MM DEW N,T (1f HEAL H AND :HU/WXl x l *+ DATE OF ISSUANCE 08/25/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN- S(ERVI9ES CERTIFICATE OF DEATH 14 01088