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STATE OF NEBRASKA ;01508416 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUNAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPAR ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL'RECORDS:� °'r DATE OF ISSUANCE 01/31/2011 Exhibit "A" ,STANLEY S CodPER R AsSISTAI T DEPTaRTMEI'T OF HEALTH AND LINCOLN, NEBRASKA ' 'HOM/4NSERV, 'ES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIeFS a , CERTIFICATE OF DEATH 11 00242 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Rodney LeRay Resh 2. SEX '. Male 3, RATE OF DEATH (Mo., Day, Yr.) ' January 24, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hastings, Nebraska 5a. AGE - Last Birthday (Yrs.) 69 5b. UNDER 1 YEAR 5c. UNDER 1 DAY '6. BATE OF BIRTH (Mo., Day, Yr.) August 2, 1941 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -44 -7063 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center ❑ 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 Buffalo 9c. CITY OR TOWN Shelton . 9d. STREET AND NUMBER 509 A.St P.O. Box 33 I9e. APT. NO. 9f. ZIP CODE I 68876 9g. INSIDE CITY LIMITS 0 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 Judith Schmidt 11. FATHER'S -NAME (First, Middle, Last, Suffix) Thurl Resh 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mildred Day 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Judith Resh 14b. RELATIONSHIP TO DECEDENT Wife . 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) January 25, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 I. CAUSE OF DEATH (See instructions and examples) 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 5 Minutes 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 In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Laryngeal Hemorrhage 24. Hours any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Largess Cancer 15 Years (disease or Injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d)Tobacco Abuse 30 Years 1 8 PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Obstructive Pulmonary Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO F FEMALE: Not pregnant within past year EI Pregnant at time of death Not pregnant, but pregnant within 42 days of death J 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 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 23a. DATE OF DEATH (Mo., Day, Yr.) January 24, 2011 Z Y u z a 3 {-1.5 K } E d h 8 w Z 8 Z 5 ~ 0 6. 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 25, 2011 23c. TIME OF DEATH 02:33 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 123d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Larry L. Hansen, 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? 0 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ❑ YES ISSUE r • ATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO P 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, HYSICIAN ASSISTANT. CORONER'S PHYSICIAN OR COUNTY A TORNEY) (Type or Print) Larry L. Hansen, MD, 3016 West Faidley, Grand Island, Nebraska, 68803 1 28a. REGISTRAR'S SIGNATURE /l.f `�- / liV 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I January 26, 2011 STATE OF NEBRASKA ;01508416 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUNAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPAR ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL'RECORDS:� °'r DATE OF ISSUANCE 01/31/2011 Exhibit "A" ,STANLEY S CodPER R AsSISTAI T DEPTaRTMEI'T OF HEALTH AND LINCOLN, NEBRASKA ' 'HOM/4NSERV, 'ES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIeFS a , CERTIFICATE OF DEATH 11 00242