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- '0 aLUV 2 tkaville ;E` AAyp rwmr STATE OF NEBRASKA xx 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, DATE OF ISSUANCE 7/5/2017 LINCOLN, NEBRASKA WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS 201708822 STATE OF NEBRASKA - DEPARTMENT! OF HEAL CERTIFICATE, OF D rH AND HUMAN SERVICES EATH I, STANLEY S.. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ronald Earl Benner 4. C ITY AND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 507 -36 -2986 8b. FACILITY -NAME (If not Institution, give street and number) Bryan Medical Center East 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln :,68506 9a :RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 249 S. Vine 10a. • MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, bit separated' :0 Widowed ❑ Divorced ❑ Unknown 9b. COUNTY Hall 11. FATHER'S -NAME (First, Middle, Last, Suffix) Conrad Benner 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Katherine Liebsack 13,:EVER •IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes; No, or Unk.) NO. .15. METHOD OF DISPOSITION E Burial ❑ Donation ❑ Cremation ❑Entombment Removal :.0 Other (Specify) 16a. EMBALMER - SIGNATURE Katie M. Smvdra 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery CITY/TOWN Grand Island STATE 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 CAUSE OF DEATH (See instructions and examples) ta, PART I. Enter the l attain 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) Ruptured Abdominal Aortic Aneurysm disease or condition resulting APPROXIMATE •1:NTERVA onset to death: Hours m deathf • eny, leading lb the' cause hsteil on line a .. ._.... DUE TO, OR AS A CONSEQUENCE OF: b) onset to death Enter the UNDERLYING CAUSE c) (disease or injury that inihate(E !in death ..;:DUE TO, OR AS A CONSEQUENCE OF: d) the events resuslrtg LAST onset todeath • 18. PART II.OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 2D. IFFEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 0 Not pregnant,hut pregnant. within 42 days of death 0 N41 pregnant bur pn&gnant 43j days to 1 year before death ❑ Unknown if pfi gnant wnhiit the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 241. INJURY AT!WORK? 3:22e. DESCRIBE HOW INJURY OCCURRED ❑YES ❑NO _ .i:? • 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a DATe OF DEATH (Mo., Day, Yr.) Julie 8 2017 DUE TO, OR AS A CONSEQUENCE OF: W q 0 l2 3d. To the best of my knowledge, death occurred at the time. dste and place and due to the cause(s) stated. (Signature and Title) 23b. DATE SIGNED (Mo., Day, Yr.) June 23 2017 Tamer Matlraus, MD TIME OF INJURY 23c. TIME OF DEATH 07:03 AM 25. DIOTOBACCO3 USE CONTRIBUTE TO THE DEATH? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be deleimined 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Tamer Mahrous,.MD, 2300 S 16th, Lincoln, Nebraska, 68502 5a. AGE Last Birthday (Yrs.) 83 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 0 Hospice Facility j 2aa. REGISTRARS SIGNATURE ) /2 � 9c. CITY OR TOWN Grand Island 5 5h. UNDER 1 YEAR MO DAYS 8d. COUNTY OF DEATH Lancaster 9e. APT. NO. 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? E YES ❑ NO 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 9f. ZIP CODE 68801 14a. INFORMANT-NAME Barbara Ann Benner 16b. LICENSE NO. 1454 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) June 8, 2017 6. DATE OF BIRTH (Mo, January 7, 1934 Day, Yr.) 9g. INSIDE CITY LIMITS II YES ❑ NO 10b. NAME OF SPOUSE (First, Harbara Ann Scott Middle, Last, Suffix) If wife, give maiden name 14b. RELATIONSHIP TO DECEDENT Wife • 16c. DATE (Mo., Day, Yr.) June 12, 2017 17b.Zip ' ; Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO' 21c. WAS AN AUTOPSY PERFORI ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑YES 0 N 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH a °r or A 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD: !a � O 24e. On the te::is of exam:nabun and/or ir.vestioation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES E 28b. DATE FILED BY REGISTRAR (Mo., Gay, Yr.) June 27, 2017