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STATE OF NEBRASKA , .r_ WHEN !' THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 RECORDS DATE OF ISSUANCE 02/17/2016 LINCOLN NEBRASKA x0160173 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENT'S - NAME (First, Middle, Last, Suffix) Eileen Delores Basnett 4 STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Michael, Nebraska 7. SOCIAL SECURITY NUMBER 507 -70 -0155 8b. FACILITY - NAME (If not institution, give street and number) Ravenna Good Samaritan Center W 8c. CITY OR TOWN OF DEATH (Include Zip Code) Ravenna 68869 ea. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 411 West Genoa Street 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Henry Muhlbach 5a. AGE - Last Birthday (Yrs.) 94 9b. COUNTY Buffalo 5b. UNDER 1 YEAR MOS. DAYS 9e. APT. NO. 12. MOTHER'S -NAME (First, Laura Meyer 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility I 8d. COUNTY OF DEATH Buffalo 9c. CITY OR TOWN Ravenna 9f. ZIP CODE 68869 10b. NAME OF, SPOUSE (First,; Middle, Last, Suffix) If wife, give maiden name Marvin James Basnett Middle, Maiden Surname) 3. DATE OF DEATH (Mo., Day, Yr.) January 20, 2016 6. DATE OF BIRTH (Mo Da September 21, 1921 Yr.) 9g. INSIDE CITY } 1MITS 0 YES ❑ NO 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes, No, orUnk.) NO Dennis Basnett 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ ; Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Tracey Dietz 1 16b. LICENSE NO. 1328 16c. DATE (Mo„ Day, Yr.) January 25, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Sodtown Cemetery CITY / TOWN Buffalo County STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Rasmussen Mortuary, 311 Grand Avenue, Ravenna, Nebraska 1 17b. Zip Code 68869 CAUSE OF DEATH (See instructions and examples) 1$. 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, 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) End Stage Vascular Dementia disease or condition resulting APPROXIMATE INTERVAL onset to death >2 Years in death) Sequentiailylist conditions, if any, leadin to tfie fisted on line a DUE TO, OR AS A CONSEQUENCE OF: b) Chronic Cerebrovascular Disease onset to death.. >10 YearS DUE TO, OR AS A CONSEQUENCE OF: c) onset to death Enter the UNDERLYING CAUSE tdisessaoriniury.that initiated. the events resultipy in death) • LAST DUE TO, OR AS A CONSEQUENCE OF: d) I onset to deetb t 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 Hypertension,, Hyperlipidemia, Chronic Arterial Fibrillation OR CORONER CONTACTED? ❑ YES NO 20. IF FEMALE: : 0 Not pregnantwi hin past year W ❑ Pregnant at time of death U ❑ not pregnant,:but pregnant within 42 days of death .'a ❑ Not pregnenI, pregnant43 days to 1 year before death ❑ 1)nknown if pregnant withitf the past year �28a. REGISTRAR'S SIGNATURE 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23a. DAT OF DEATH (Mo., Day, Yr.) January 2Q,,2016 v P 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH E z January 27 2016 07:30 AM ,4 Q 0 3 tl. To the best of my knowledge, death occurred at the time, date and place g O and due to the cause(s) stated. (Signature and Title) Z : Steven Husen, MD attripeot- 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL 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 ATWORK? 22e. DESCRIBE HOW INJURY OCCURRED YES ❑ NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 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) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES fl NO 28b. DATE FILED BY REGISTRAR (MO.r'Day, Yr.) February 9, 2016 STANLEY S. OPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES