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STATE OF NEBRASKA tY W U. 1= W U 0. E 0 w p 0 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 ECORDS A air DATE OF ISSUANCE 201706710 8/30/2016 LINCOLN, NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Vernon John Larson 4. CITYAt4D STATE OR T ERRITORY, OR FOREIGN COUNTRY OF BIRTH Brayton, Nebraska 7. SOCIAL SECURITY NUMBER 507 -3.8 -6153 FACILITY -NAME (If not institution, give street and number) 300 East Schultz Rd 8c. CITY OR TOWN OF DEATH (Include Zip Code) Doniphan 68832 9a RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 300 East Schultz Rd 10a. MARITAL STATUS AT TIME OF DEATH Ei Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Arthur Larson 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, Na, or Unk) Yes 02/02/1953-01/28/1955 1 5. METHOD OF DISPOSITION 16a. EMBALMER - SIGNATURE ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal '❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska 18 20. IFFEMALE: ❑ Not pregnant Thin past year ❑ Pregnant at time of death Not pregnanit,.but pregnant within 42 days of death Not pregnant,: but pregnant43 days to 1 year before death Unknown if pregnant withinthe past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d..INJURY. AT >WORK?':. DYES DNO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) Avm:st 23, 2016 23b. DATE SIGNED (Mo., Day, Yr.) August 24, 2016 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall Katie M. Smvdra 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 21a. MANNER OF DEATH El Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23c. TIME OF DEATH 05:22 PM 3d. To the best of my knowledge, death occurred at the time, date andplace and due to the cause(s) stated. (Signature and Title) 5a. AGE - Last Birthday (Yrs.) 14a. INFORMANT -NAME Karlene Gayle Larson CITY /TOWN 87 Sb. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Doniphan CAUSE OF DEATH (See instructions and examples) 16b. LICENSE NO. 1454 0 Pedestrian n other; (SpecirY) DAYS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 7 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient G ER/Outpatient ❑ DOA 8d. COUNTY OF DEATH Hall OTHER ❑ Nursing Home /LTC Decedent's Home ❑ Other (Specify) Grand Island 10b. NAME QF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden na Karlene Gavle Olson 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Magdalena Hendrickson CITY /TOWN 9f. ZIP CODE 68832 3 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, 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) Metastatic Prostate Cancer disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: I 1 Sequentially list conditions, if b) any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE O) (disease or injury that initiated the events resulting !In death) ' DUE TO, OR AS A CONSEQUENCE OF: LAST d) PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. STATE August 25, 2016 3. DATE OF DEATH (Mo., Day, Yr.) August 23, 2016 6. DATE OF BIRTH (Mo.. Day, Yr _ September 26, 1928 ❑ Hospice Facility 9g. INSIDE CITY LIMITS ❑ YES ® NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) August 27, 2016 STATE Nebraska 17b, Zip Coda 68801 APPROXIMATE INTERVi onset to death Months 21b. IF TRANSPORTATION INJURY WAS AN AUTOPSY PER FO ❑ Driver/operator ❑ YES El NO ❑ Passenger onset to death onset to de ath': 19. WAS MEDICAL EXAMINE,R OR CORONER CONTACTED? ❑ YES NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) ) 2413. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD ZIP CODs 13y, iY Li J E U . Ja O S U r° g Travis S. Hageman, MD '' - 25. DID TOBACCO USE CONTRIBUTE 10 THE DEATH? 26a AS O AN TISSUE DONATION BEEN' CONSIDERED? 26b. WAS CONSENT GRANTED? ., I. d YES E3 NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ID NO I Not Applicable if 26a is NO ❑ YES 0 N 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 8a. REGISTRARS SIGNATURE 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), 28b. DATE FILED BY REGISTRAR €( ED C CD tl O) CD