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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN'SERVICES, IT CERTIFIES THE 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 02/13/2012 201806640 STANLEY S. COOPER ASSISTANT .TATr REGISTRAR DEPARTMENT OF -HEALTH AND HUMAN SERVICES LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 12 00423 To be completedNerified by: FUNERAL DIRECTOR 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Kenneth Luther Craven 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) February 4, 2012 4. CITY AND STATE OR 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.) Litchfield, Nebraska (Yrs.) 82 MOS. DAYS HOURS MINS. April 7, 1929 7. SOCIAL SECURITY NUMBER 508-30-9018 8a. PLACE OF DEATH HOSPITAL ❑ inpatient OTHER ® Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Park Place -A Golden Living Center 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (include Zip Code) Grand Island 68803 ad. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1011 South Pine 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name Edna Lee Tucker 11. FATHER'S -NAME (First, Middle, Last, Suffix) William Henry Craven 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Asenath Keown McAlevy 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Edna Lee Craven 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) February 7, 2012 ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Kleine Funeral Home, 3213 W. North Front Street, Grand Island, Nebraska for DeWitt Funeral & Cremation Service, Inc., 1247 N. Burlington Ave, Hastings, Nebraska 17b. Zip Code 68803 68901 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART I. 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 if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) End Stage Vascular Dementia disease or condition resulting onset to death About 1 Year i,: da::n) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)Chronic Cerebrovascular Disease any, leading to the cause listed on line a. onset to death About 5 Years DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Type 2 Diabetes, Hyperlipidemia (disease or injury that initiated onset to death More Than 20 Years 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. Arteriosclerotic Cardiovascular Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 0. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH ® Natural 0 Homicide ❑Accident 0 Pending investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑YES ®NO ❑ 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 0 suicide 0 Could not be determined 0 Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES ❑ 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? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) February 4, 2012; a 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) February 6, 2012 23c. TIME OF DEATH 11:20 AM 73 s ° Y fl a < C 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD th 23d. To e best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Steven Husen, MD u K 8 z e O O 24e. Oh theibasis of examination and/or investigation, ion, in and opinion natre deathTitle)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? 0 YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, SICiAN ASSISTANT, CORONER'S -PHYSICIAN OR COUNTY Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE ,- -ATTORNEY) (Type or Print) 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I February 8, 2012