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F 7/ 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 LINCOLN, 2NEBRASKA ASSISTA RUSSELL FOSLER DEPARTMENT HEALTH AND INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 18 09958 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) Roger Lee McShannon 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) July 31, 2018 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.) Bloomfield, Nebraska (Yrs.). 76 ` MOS. DAYS HOURS MINS. March 3 1942 7. SOCIAL SECURITY NUMBER 508-40-7576 8a. PLACE OF DEATH HOSPITAL igiInpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACIL)TY-NAME (If not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatient D Decedent's Home 0 DOA ' ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska : 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER e. APT. NO. 809 S. Vine St. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married 0 Married, but separated ❑ Widowed ❑ Divorced 0 Unknown 10h. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Sharon Kay Wegner 11. FATHER'S -NAME (First, Middle, Last, Suffix) ` 12. MOTHER'S -NAME (First, Middle, Maiden Surname) John McShannon I Minnie Stark 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link.) No 14a. INFORMANT -NAME Sharon Kay McShannon 14b. RELATIONSHIP TO DECEDENT Spouse 15 METHOD OF DISPOSITION ®Burial 0 Donation 16a. EMBALMER -SIGNATURE Stacie L. Ruiz 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr,) August 6, 2018 ❑ Cremation 0 Entombment ❑`Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION Grand Island City Cemetery CITY / TOWN STATE 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 17b3, Zip Code 68801 CAUSE OF DEATH, (See instructions and examples) 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 Rile. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Lung Cancer, Metastatic disease or condition resulting onset to death Months in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list Conditions, if '. b) any, leading to the cause listed on line a. onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ; E NO 20. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH E Natural 0 Homicide ❑ Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passen ger g 21c. WAS AN AUTOPSY PERFORMED? 0 YES ® NO ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year ❑ Suicide 0 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? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE o tr 23a. DATE OF DEATH (Mo., Day, Yr.) July 31, 2018 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH s} 23b. DATE SIGNED (Mo., Day, Yr.) 2 21 u i August 2, 2018 23c. TIME OF DEATH 07:45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD g u O o It " 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) Travis S, Hageman, 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? 0 YES 0 NO 0 PROBABLY E UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?' ❑ YES E NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S, Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.}<...I August 7, 2018