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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 RECORDS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 9/5/2017 LINCOLN, NEBRASKA 201901349 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH To completed/verified by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Edward Dean Rawlings 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) August 21, 2017 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 68 MOS. DAYS HOURS MINS. December 3, 1948 7. SOCIAL SECURITY NUMBER 508-64-1822 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility Sb, FACILITY -NAME (If not Institution, give street and number) CHi Health St. Francis ❑ ER/Outpatient ❑Decedent's Home 0 .cA ❑ 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 420 N Cherokee Ave. 9e. APT. NO. 9f. ZIP CODE 68803 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 Carol Scheffler 11. FATHER'S -NAME (First, Middle, Last, Suffix) Paul Rawlings 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Hazel Butterbaugh 15. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or link) No 14a. INFORMANT -NAME Carol Rawlings 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF pI$POSITIQN ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Gay, Yr.) August 24, 2017 ® Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Crematory i Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston -Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska 17b. Zip Code 68803 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. 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 8 line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Pulmonary Fibrosis disease or condition resulting onset to death 2 Months in death/ DUE TO, OR AS A CONSEQUENCE OF: ' onset to death Sequentially list conditions, if :. b) Opdivo Therapy ; Months any, leading to the cause listed '.- on incla. DUE TO, OR AS A CONSEQUENCE OF: Einer the UNDERLYING CAUSE C) Stage 4 Non Small Cell Lung Cancer (disease Of injury that initiated onset to death 15 Months the events resuhing'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. Hypertension, Obstructive Sleep Apnea, Depression, Obesity, Impaired Fasting Glucose, Prostate Cancer 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20.1F FEMALE: ❑ Not pregnant within peat year ❑ Pregnant at time of death 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ®NO ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ unknown if pregnant Witten 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 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 0 N 22e. DESCRIBE HOW INJURY OCCURRED , 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE fTo be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) August 21, 2017 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.) August 22, 2017 23c. TIME OF DEATH 12:47 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD '3d. To the nest of my knowledge, neat: occurred at the time, date and place and due to the cause(s) stated. (Signature and Titie( Adam Brosz, MD - 34e. 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 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 (Type or Print Adam Brosz, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE Ai- avow"- yV w 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 24, 2017