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To be completed /verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Raymond Hauser 2. SEX ' Male 3. DATE OF DEATH (Mo., Day, Yr.) August 5, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Platte Center, Nebraska 5a. AGE - Last Birthday (Yrs.) 90 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) January 31, 1925 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -20 -8880 Bb. FACILITY -NAME (If not Institution, give street and number) 4075 Timberline Street 8a. PLACE OF DEATH HOSPITAL 0 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 9d. STREET AND NUMBER 4075 Timberline Street 9e. APT. NO. 9f. ZIP CODE 68803 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 Marcella Menke 11. FATHER'S -NAME (First, Middle, Last, Suffix) Raymond Hauser 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lena Hembd 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 10/28/1943- 04/22/1946 14a. INFORMANT -NAME Marcella Hauser 14b. RELATIONSHIP TO DECEDENT Spouse 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.) August 8, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 TOWN STATE Shell Creek Baptist Cemetery Columbus Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Gass Haney Funeral Home, 2109 14th Street, Columbus, Nebraska 17b. Zip Code 68601 u 1 To be completed by: CERTIFIER 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 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) Natural Causes disease or condition resulting n death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death Sequentially list conditions, if b) t any, leading to the cause listed 1 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 the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 1 - l. 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 OR CORONER CONTACTED? ® YES ❑ NO I. 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 I 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? DYES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) 7— T7 - 2e completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) August 7, 2015 24b. TIME OF DEATH 12:01 PM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) August 5, 2015 24d. TIME PRONOUNCED DEAD 01:10 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 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) Jack Zitterkopf, Hall County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑YES ®NO 28b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑YES ❑ NO Not 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jack Zitterkopf, Hall County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 • 128a. REGISTRAR'S SIGNATURE _ �_ � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) 28 August 7, 2015 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAYTy ANb"I N SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB 5kA IbEigit T OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR �VITAl R.ECO I :f1 0 DATE OF ISSUANCE 201603714 STA ' ASS T ' PJT DEPARTMENTI LINCOLN, NEBRASKA HUMAN SER.YF STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV CERTIFICATE OF DEATH 08/11/2015 r'>I E GJ7,lAR F frd#'A'LtTtI AND • 15 04600