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STATE OF NEBRASKA 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 STANLEY SOOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES DATE OF ISSUANCE 8/30/2016 LINCOLN, NEBRASKA 20170337 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Vernon John Larson 4.:CITY.AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Brayton, Nebraska 7. SOCIAL SECURITY NUMBER . 507 -38 -6153 8{k FACILITY -NAME (I nOt.:InstItutIon, give street and number) 300 East Schultz. Rd Enter the UNDERLYING CAUSE tdlseas4:prujury:Ifst Initial the events rgsuit(ttg ::in death) . LAST:: . >: .. 23a. DATE Of DEATH (Mo., Day, Yr.) :;. Auqust23; 2016 J z () 9d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and nu e) >Travis:S; Hageman, MD 231i DATE SIGNED (Mo., Day, Yr.) August 24, 2016 23c. TIME OF DEATH 05:22 PM 25. DID TOBACCO USE:: CONTRIBUTE TO THE DEATH? ❑ YES FJ NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE - Last Birthday (Yrs.) • 87 : 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑.. ERIOutpatient ❑DOA 5b. UNDER 1 YEAR MOS. DAYS 26a. HAS ORGAN OR TISSUE DONATION BEEN:. CONSIDERED? ❑ YES ® NO 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home/LTC ® Decedent's Home ❑ Other (Specify) CAUSE OF DEATH JSee instruc igns and examples) i& PART: I: Enter the charm of e vents - - 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. 24a. DATE SIGNED (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) August 23, 2016 6. DATE OF BIRTH ::(MO.,: Day, ::Yr.) September 25 ::1928' .':. ❑ Hospice Facility 8c. CITY OR TOWN OF DEATH (Include Zip Code) Don.iphan .68832 I 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE 1 18b. COUNTY Nebraska > Hall Sc, CITY OR TOWN Dor Phan.... 9d. STREET AND NUMBER 300 East Schultz Rd 9e. APT. NO. 19f. ZIP CODE 68832 9g. INSIDE CITY LIMITS t ❑ YES ® NO ISa. MARITAL STATUS:•AT TIME OF DEATH ® Married ❑ Never Married ❑. Married, but separated > ❑ Widowed ❑ Divorced ❑ Unknown l0b. NAME OF SPOUSE (First, . Middle, Last, Suffix) If wife, give maiden name Karlene .Gavle Olson I 12. MOTHER'S -NAME (First, Middle, 11. FATHER'S -NAME :(Fist, Middle, Last, Suffix) Arthur Larson Magdalena Hendrickson Maiden Surname) 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yes; No or link;) yes :: 02/02/1953- 01/28/1955 Karlene Larson 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD?OF DISPOSITION 16a. EMBALMER-SIGNATURE ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ ReirlSval :0 Other(SpecifY) Katie M. Smvdra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) August 27. 2016 18d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery . CITY / TOWN STATE Grand Island Nebraska 17a. FUNERAL HONE NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island; Nebraska 17b Ztp Code 68801 IMMEDIATE CAUSE: IMMEDIATE CAUSE Masi a) Metastatic Prostate Cancer disease or condition resulting APPROXIMATE: INTERVAL onset to death Months In :deathi:�..:;: • Segttlltltially'tisl conditione, : iI any, laadin9lathe•ceiise•hated on lino DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: C) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 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 OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE::::::;::. 0 Not gnantistthm Past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death p i Not pregnant,. but pregnant: 43 days to t year before death ❑ Unknown pregnant within: the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b4F TRANSPORTATION INJURY ❑ OrWSr/Operator ❑ Passenger ❑ Pedestrian ❑ OtheriSPecify) 21c. WAS AN AUTOPSY PERFORMED ? : : ❑YES Ea NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 122c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sib, etc. (Specify) 22d INJURY AT 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 TIN) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO [. YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travt S. I-tagem.an, MD, 729 North Custer Avenue, Grand Nebraska, 68803 78a /� REGISTRAR`S SIGNATURE _ a 28b. DATE FILED BY REGISTRAR (Mo., Day Yr) August 25, 2016