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STATE OF NEBRASKA ST A 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 DATE OF ISSUANCE 10/24/2017 LINCOLN, NEBRASKA 201707790 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S.wCOOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Francis Herman Harders 4. CIfl AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Rural Wood River, Nebraska 7. SOCIAL SECURITY NUMBER 506 -46. -0546 8b. •FACILITY•NAME (If not Institution, give street and number) CHI Health St Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803. 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9d. STREET AND NUMBER 4320 Sherwood Road Oa, MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated •:❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S-NAME (First, Middle, Last, Suffix) Otto R Harders 412. MOTHER'S -NAME (First, Middle, Maiden Surname) Marie L Eich 13..EVER IN U.S.` ARMED FORCES? Give dates of service if Yes. (Yes; No, Or urk.) Yes 05/08/1951-04/28/1953 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment R moval 0 Other (Specify) 16a. EMBALMER- SIGNATURE Tracey Dietz 16d. CEMETERY, CREMATORY OR OTHER LOCATION St. Mary's Cemetery CITY / TOWN Wood River STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfei Funeral Home, 1123 W. 2nd. Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) 1k. PART I. Enter the ;Chain ofeve to -- diseases, injuries, or complications -that directly caused the death.DO NOT enter terminal events such as cardiac arrest, respiratotyerrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause art a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest disease or condition resulting onset to death Minutes APPROXIMATE INTERVAL in death) Sequetitlauy list cend(gons, H any, leading tothe gsted> on line a UE TO, OR AS A CONSEQUENCE OF: b) Pulmonary Fibrosis onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease m injury that mitlated onset to death the events resulti ur,death DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PART 1I. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20. IF FEMALE: .: ❑ Not pr gnant within past year ❑ Pregnant at time of death Net pregnant„ but pregnantwithin 42 days of death ❑ Net pregnant, but pregnant da. days to 1 year before death ❑ Unknown if pregnant wnbiflthe past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURYATWORK? j]Yss ❑NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 23a.. DATE OF 13EATH (Mo., Day, Yr.) u : J Z a O i 3d. To the best of my knowledge, death occurred at the time, date and place g 5 and due to the cause(s) stated. (Signature and Title) 23b. DATE SIGNED (Mo., Day, Yr.) • 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22e. DESCRIBE HOW INJURY OCCURRED 23c. TIME OF DEATH 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO 0 PROBABLY ® UNKNOWN 5a. AGE - Last Birthday (Yrs.) 86 28a. RE - ` mss 5b. UNDER 1 YEAR MOS. DAYS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ® ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand Island 8d. COUNTY OF DEATH Hall 10b. NAME OF SPOUSE (First, Charlotte McAllister' Middle, Last, Suffix) If wife, give maiden name 14a. INFORMANT-NAME Charlotte !Herders b, LICENSE NO. 1328 21b, IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Othef (Specify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) October 17, 2017 240, PRONOUNCED DEAD (Mo., Day, Yr.) October 14, 2017 26a. HAS ORGAN OR TISSUE DONATION BEENI CONSIDERED? ❑ YES El NO 9f. ZIP CODE 68803 3, DATE OF DEATH (Mo., Day, Yr.) October 14, 2017 October 27, 1930 6. DATE OF BIRTH (Mo., Day, Yr.) October 18, 2017 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) October 18, 2017 17b. Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 21c. WAS AN AUTOPSY PERFORMED? :: ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES El NO 24b. TIME OF DEATH 04:12 AM 24d. TIME PRONOUNCE DEAD 04:12 AM 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) Gail VerMaas, Hall Deputy County Attorney 26b. WAS CONSENT GRANTEVk.Er Not Applicable if 26a is NO ❑ YES Q NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gail VerMaas, Hall, Deputy County Attorney, 231 S Locust P.O. 8 x 367 Grand Island, Nebraska, 68802 28b. DATE FILED BY REGISTRAR Mo., Day, Yr.) O C ff .'s.