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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Larry Richard Baumgartner 2. SEX Male 3 -DATE OF DEATH (Mo., Day, Yr.) November 27, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Santa Ana, California 5a. AGE • Last Birthday (Yrs.) 73 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) August 27, 1941 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -50 -9424 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Horne ❑ 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 9d. STREET AND NUMBER 552 East 18th Street e. APT. NO. r 8f. ZIP CODE I 68801 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 Maxine Powell 11. FATHERS-NAME (First, Middle, Last, Suffix) Leonard Baumgartner 12. MOTHERS-NAME (First, Middle, Maiden Sumame) Hazel Sparks 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Maxine Baumgartner 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) December 2, 2014 16d CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Cedarview Cemetery Doniphan Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 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, 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) Coronary Artery Disease disease or condition resulting onset to death Years in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, If b) I any, leading to the cause listed I online a. DUE TO, OR AS A CONSEQUENCE OF: 1 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 II. OTHER SIGNIFICANT CONDITIONS •Conditions contributing to the death r • not resulting in the underlying cause given in PART I. Chronic Obstructive Pulmonary Disease Peripheral Vascular Disease, Pneumonia 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time f death me oea 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 ❑ Accident ❑ Pending Investigation ❑ 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 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 A W i rc r E z 23a. DATE OF DEATH (Mo., Day, Yr.) November 27, 2014 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 5, 2014 23c. TIME OF DEATH I 03:46 PM 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD s u O 3d. To the best of my knowledge, death occurred at the time, date and place G and due to the cause(s) stated. (Signature and Title) ~ 2 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 causes) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 13 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ❑ YES SSUE r • 13 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 Nebraska, 68803 128a. REGISTRARS SIGNATURE A . 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 9, 2014 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH 4NQ,(AltIAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB RA5K D PART M1 OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOIZ VITA .� itECORbS. -. 4x60261$ DATE OF ISSUANCE 12/12/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA STeINLEY S. COOPER 44g515TA 9r r A7 R GISTJ44R; DERARnialtb AL AND Nlito RN SERVICES y' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIlES CERTIFICATE OF DEATH ac+ 2(44 %8556 14 06325