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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) - Stephen Frederick Ronshaugen 2. S , Male " 3.13ATI: OFDEATH (Mo., Day, Yr.) i April 5, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Webster, South Dakota 5a. AGE - Last Birthday (Yrs.) 66 5b. UNDER 1 YEAR 5c. UNDER 1 DAY' S. DATE OF BIRTH (Mo., Day, Yr.) March 23, 1948 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 504 -58 -9641 Sb. FACILITY -NAME (If not institution, give street and number) Tiffany Square Care Center 8a. PLACE OF DEATH HOSPITAL ❑ 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 Ha. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island STREET AND NUMBER 2525 South August Street re. e. APT. NO. 8f. ZIP CODE ! 68801 9g. INSIDE CITY LIMITS El YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH El Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Janet Carol DeMarais 11. FATHER'S -NAME (First, Middle, Last, Suffix) Hjalmer Ronshaugen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Josie Aspen 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Janet Carol Ronshaugen 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Daniel D Naranjo 16b. LICENSE NO. 1071 16c. DATE (Mo., Day, Yr.) April 11, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 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 4 Years 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 Squamous Cell Carcinoma Lung disease or condition resulting 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 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: i onset to death LAST d) 1 I 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the d but not resulting in the underlying cause given in PART I. Chronic Obstructive Pulmonary Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant time of death oeath 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 Rion ❑ 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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE .0 W 1 F E u El 23a. DATE OF DEATH (Mo., Day, Yr.) April 5, 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.) A pril 8, 2014 23c. TIME OF DEATH I 02:10 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD g U O 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) La it Ryan D. Crouch, DO 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE A _ , � p � V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 10, 2014 DATE OF ISSUANCE WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH, ND HUMAN SERVICES, IT CERTIFIES THE 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 FOIE IgT,AL RECORDS., 04/15/2014 STATE OF NEBRASKA 201707060 sTAl1(LEY v O ER W, -ASSISTANT STATE REGISTRAR DEPAZTnigiv V HEALTH AND LINCOLN, NEBRASKA --HUMAN SER I STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S R\1IdES CERTIFICATE OF DEATH 14 01744