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STATE OF NEBRASKA 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 8/13/2018 LINCOLN, NEBRASKA RUSSELL FOSLER DEPARTMENT HEALTH AND INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jack Arthur Richardson 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) July 30, 2018 4. CITY AND STATE QR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 71 MOS. DAYS HOURS MINS. February 11, 1947 7. SOCIAL SECURITY NUMBER 508-54-3764 8a. PLACE OF DEATH HOSPITAL E} Inpatient - OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hail 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 303 Waldo Ave 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS Ei YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 106. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Carol Straube 11. FATHER'S -NAME (First, Middle, Last, Suffix) Junior Arthur Richardson 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Daisy Marie Starkey 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) No 14a. INFORMANT -NAME_ Carol Richardson 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Stacie L. Ruiz 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) August 3, 2018 ❑ Cremation 0 Entombment ❑:Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn 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) 15. PART 1 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_ respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines A necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) End Stage Chronic Obstructive Puunarary Disease With Chronic Respiratory Failure disease or condition resulting onset to death 2 Weeks in death)onset DUE TO, OR AS A CONSEQUENCE OF: Sequentially listconditions, it : b) any, leading to the cause listed a. to death on line DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) tdisease or injury, that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) 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. End Stage Congestive Heart Failure 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 20. IF FEMALE: 0 Not pregnant within past year 0 Pregnanto Pnant at timef death 21a. MANNER OF DEATH El Natural ❑ Homicide ❑ Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY ❑'Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED'? 0 YES ®NO 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year ❑ Suicide ❑ Could not be determined 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 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? OYES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) ' Ju)v 30, 2018 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.) July 30, 2018 23c. TIME OF DEATH 10:14 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Richard Frueh(ing, MD 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 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 2 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidiey #400, Box 9802; Grand Island, Nebraska, 68803 29a. REGISTRAR'S SIGNATURE . 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 7, 2018 �'�-------