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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 DATE OF ISSUANCE 1/22/2018 LINCOLN, NEBRASKA RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS STANLEY . COOPER v 201801792 ASSISTA�I STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH K 0 CC W a a a 0) tb 1v 0. E 0 01 A I 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Ruth Louise Larson 4 CITY STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 506 -26- 7850 Sb. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Grand Island Village 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9d. STREET AND NUMBER 410 S. Sycamore 10a. MARITAL. STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated', ® Widowed ❑ Divorced ❑ Unknown 5a. AGE 'r- Last Birthday (Yrs.) 87 5b. UNDE 1 YEAR MOS. DAYS 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) January 15, 2018 6. DATE OF BIRTH (Mo, Day, Yr.) September 9, 1930 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ® Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 90. CITY OR TOWN Cairo 9e. APT. NO. 9f. ZIP CODE 68824 9 INSIDE CITY donna'' ® YES ❑ NO lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Robert Conrad Larson 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Wesley Elliot Sorensen Helen Louise Hulett 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION 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 DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CRUSE c) (disease. or Injury •that inklatatt . the events result ngrn death) (AST_ .....£: ........._i'. 20. IF FEMALE: ❑ Not pregnant within past year 0 Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown it pregnant Wdhin the past year 22a. DATE OF INJURY (Mo., Day, Yr.) . DATE OF DEATH (Mo., Day, Yr.) January 15 , 2018 23b. DATE SIGNED (Mo., Day, Yr.) January 17, 2018 16a. EMBALMER- SIGNATURE Katie M. Smvdra 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Mt. Pleasant Cemetery Cairo STATE Nebraska 22b. TIME OF INJURY 23c. TIME OF DEATH 05:20 AM 23d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) Jennifer L. Brown, MD 25. DID TOBACCO': USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation 0 Suicide ❑ Could not be determined 1 28REGISTRA RS SIGNATURE 1 3 - III - 14a. INFORMANT -NAME Seanne Ernerton 21b. IF TRANSPORTATION 0 Driver/Operator ❑ Passenger 0 Pedestrian 0 other lSpecify) 24a. DATE SIGNED (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ®NO 6b. LICENSE NO. 1454 INJURY 14b. RELATIONSHIP TO DECEDENT Daughter;.. 16c. DATE (Mo., Day, Yr:) sl January 27, 2018 17b, ZIP Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the Chain of overits -- diseases, injuries, or complications -that directly caused thedeath, 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 tines Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting APPROXIMATE INTERVAL onset to death < 1 Week in death) DUE TO, OR AS A CONSEQUENCE OF: senga list 40m:idions,if b)Metastatic Cancer, Likely Pancreatic <.' any, leading to the (cause listed on line a onset to death> < 1 Year onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 21c. WAS AN AUTOPSY PENFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24e. On the basis of examination and /or investiga ion, 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 REGISTRARIMo., Day, Yr.) January 17, 2018 22d. INJURYAT. WORk ❑ YES ❑.NO 1 22e. DESCRIBE HOW INJURY OCCURRED 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 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803