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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ronald Carl Shullaw 2. SEX Male 9/ DATE O o., Day, Yr.) July-12;20 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Ottumwa, Iowa 5a. AGE - Last Birthday (Yrs.) 72 5b. UNDER 1 YEAR Sc. UNDER 1 DAY _ �, ":6. DATE OF BIRTH (Mo., Day, Yr.) April 17, 1942 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 480 -48 -3516 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 Doniphan 9d. STREET AND NUMBER 334 Sunset Dr. 9e. APT. NO. 9f. ZIP CODE 68832 9g. INSIDE CITY LIMITS I ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ID Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Norma Jane McCown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Richert Shullaw 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Edith Nicoles 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 04/25/1959- 04/30/1963 14a. INFORMANT -NAME Norma Jane Shullaw 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) July 17, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Wyuka Cemetery Lincoln Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Ali 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 1e. 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, r 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) Plasma Cell Leukemia disease or condition resulting onset to death Months in death) DUE TO OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b) Multiple Myeloma 1 Years any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated I 1 the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) 1 onset to death 1 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART 1. Pseudomonas Bacteremia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ 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 H pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pen< R ❑ Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 2' W i z r E o , 23a. DATE OF DEATH (Mo., Day, Yr.) July 12, 2014 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 14, 2014 23c. TIME OF DEATH 03:40 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD < g 0 Sd. To the best of my knowledge, death occurred at the time, date and place O and due to the cause(s) stated. (Signature and Title) t 2 m Travis S. Hageman, 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 Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ❑ YES SSUE r • IZI NO ATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island , 68803 128a. REGISTRAR'S SIGNATURE /L� I/� _� _ I {_if_�_J�V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I July 17, 2014 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANQ HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS/G4 bEP RTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSI � ',, FOR VITAL RECIOIbS• _• • DATE OF ISSUANCE 7/21/2014 STATE OF NEBRASKA 20 1504246 S7' ASSIS,TA DEPARTM LINCOLN, NEBRASKA HIJMA& SER STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN. SfR\(ICES CERTIFICATE OF DEATH 14 03511