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"A; a r M a " 411 wi 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 201804595 STANLEY COOPER ASSISTA STATE REGISTRAR 6/14/201 8 DEPARTMENT HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH wwWisle 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ronald Leo Harders 4. CI AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 506-84-0782 5a. AGE - Last Birthday (Yrs.) 60 5b. UNDER 1 YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ inpatient 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) May 28, 2018 August 31, 1957 6. DATE OF BIRTH (Mo., Day,Yc) OTHER ❑ Nursing Home /LTC ❑ Hospice Facility 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9d. STREET AND NUMBER 1421 Lilley Street 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married Q,Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Urk.) ND 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal . ❑ Other, (Specify) 16a. EMBALMER - SIGNATURE Gwen K. Hyronemus 9c. CITY OR TOWN Wood River 9e. APT. NO. 9f. ZIP CODE 1 68883 10b. NAME OF SPOUSE (First,. Mary A Preuss Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S•NAME (First, Middle, Last, Suffix) Lyle Harders 12. MOTHER'S -NAME (First, Middle, Frances Runge Maiden Surname) 14a. INFORMANT -NAME MaryA Harders 1 6b. LICENSE NO. 1448 16d. CEMETERY, CREMATORY OR OTHER LOCATION Berwick Cemetery CITY / TOWN Cairo STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Aofel Funeral Home. 1123 W. 2nd. Grand Island, Nebraska 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr) June 2, 2018 17b, Zip Code 68801 CAUSE OF DEATH (See instructions and examples) b. FACILITY - NAME If net, Institution, give street and number) 1421 Lilley Street 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883 8. PART L 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 (Final disease or condition resulting in death} Seguentiatly listcoiidittons,)f any leading to the mdse :isten on line 0. .. _._.. _....... 23a. DATE OF DEATH (Mo., Day, Yr.) IMMEDIATE CAUSE: . _. a) SLrer rd Arrest DUE TO, OR AS A CONSEQUENCE OF: b)Arrythmia o a U I»3d. To the best of mr areneedge, death cccurred.at the time, date and place 2 O and due to the cause(s) stated. (Signature and Title) 2 DUE TO, OR AS A CONSEQUENCE OF: C) onset to death Enter the UNDERLYING CAUSE 161se00 or injury that inttiat 11 the euentS esuaifig in death) LAST DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. AI04ho1 Use, Tobacco Use 20. IF FEMALE: ❑ Net pregnant Within past year ❑ Pregnant at time of death ❑ . pregnent,:but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Ilnienewn if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d1NJURY ATWORK? i ❑YES ❑ NO 22b. TIME OF INJURY 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident ❑ Pending Investigation ❑ Suicide ❑ Coufd not be determined 21b IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger 0 Pedestrian 0 Other (Specify) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? IX1 YES `. ❑ NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 1 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF.DEATN? 0 YES ❑ 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH - 25. DID TOBACCO USE GONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ® PROBABLY ❑ UNKNOWN 26a. HAS OR ❑ YES 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Katherine J. Doering, Deputy County Attorney, 231 South Locust, Grand Island, Nebraska, 68801 1 280. REGISTRAR'S SIGNATURE 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD May 28, 2018 03 :30 PM 244. 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) Katherine J. Doering, Deputy County Attorney AR OR TISSUE DONATION BEEN CONSIDERED? NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRA June 8, 2018 n eNto uto" ent 0 DOA 4 24a. DATE SIGNED (Mo., Day, Yr.) J une 6, 2018 8d. COUNTY OF DEATH Hall li Denerlent'e Home ❑ Other (Specify) APPROXIMATE INTERVAL onset to death onset to death Seconds 24b. TIME OF DEATH Unknown