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Kansas Department of Health and Environment Office of Vital Statistics' CERTIFICATE OF DEATH AMENDED -1.2/19/2018 1. Decedent's Legal. Name (First; Middle, Last) RANDALL ALAN SHACKLETON 2. Sex MALE 3, Date. Of Death (Month, Day, Year) 11/12/2018 4. Social Security Number 506-90-5403 201902130 115-2018-23340 State File Number 5. Date Filed By State Registrar 11/28/2018 6. Last.Name Prior to.FRrst Marriage SHACKLETON 102, Place: Of Death: 7a. Date Of Birth 12/15 1960 7b. Age 57 YEAR(S) 8. Place Of Birth (City And State. Or Foreign Country) OXFORD, NEBRASKA Armed 9. Decedent Ever In U.S. Forces NO ER/OUTPATIENT 10e, CIty or Town Of. Death KANSAS CITY 10b. Facility Name (If Not Institution, Street And Number) PROVIDENCE MEDICAL CENTER 11. Marital Status MARRIED 12. Surviving Spouse (Name Prior to First Marriage) MARJORIE LARSON 10c. County Of Death WYANDOTTE 13a. Residence - Street Address 2820 BRENTWOOD BLVD 10d. Zip Code 66112 13b= State or Foreign. Country NEBRASKA: 13c. County or Province HALL 13d.: City or Town. GRAND ISLAND 16. Decedent's Hispanic Origin NOT SPANISH, HISPANIC, IATlNO:: 17. Decedent's Education 15. Decedent's Race WHITE 20. father/Parent Birth Name(FlrSt, Middle, Last) WILLIAM CLARK SHACKLETON 22a,:lnformant s Name (First, Middla,: last) MAR70RIE SHACKLETON 18. Decedent's Occupation MUSIC TEACHER 25: funeral Service Licensee Arid License Number /e/SAMUEL E GARCIA 3099 13e. Zip Code 68801 19. Decedent's Industry SCHOOL 21. Mother/Parent Birth Name (First, Middle, Last) WANDA MARIE ROBERTS 22b. Mailing Address (Street, Number, Crty, State, And Zip Code) 2820 BRENTWOOD BLVD, GRAND ISLAND, NEBRASKA, 68801 24a. Place Of Disposition 1NESTLAWN MEMORIAL PARK CREMATORY 24b. Location 13f. Inside City Limits YES 22c. Relationship To Decedent WIFE GRAND ISLAND, NEBRASKA 26. Name Of Embalmer And License Number SAMUEL E GARCIA - 3970 27. niame And Address Of firm 'LARKIN AM) GARCIA FUNERAL CARE, 1844 MINNESOTA AVE, KANSAS CITY, KANSAS, 66102 2&: Cause Of Death Part I. Events (diseases, injuries, or complications) that directly caused the death. IMMEDIATE CAUSE(Flnal Disease Or Condition Resulting in Death)': Conditions, If any, leading To cause listed on line A) UNDERLYING CAUSE (disease or Injury that Initiated the events resulting lit death).; LISTED LAST A) CARDIAC ARREST B) CORONARY ARTERY DISEASE Part U. Other Significant Conditions Contributing To Death But Not Resulting In The Underlying Cause Given In Part I. DIABETES MELLITUS, SLEEP APNEA 30. Did Tobacco Use Contribute. To Death? NQ;. 29a. Autopsy NO 33b. Time Of Injury 33c. Injury At Work 33d. How Injury Occurred 34a. Date Pronounced Dead 11/12/2018 353. Pronouncing and Certifying Physldan /e/I$AAC J BERG -.MD 16231A -Rev. 10/1112016 02/28/2019 V210000256201 01 SHACKLETON 201804023340 5 @@ 34b. Time Pronounced Dead 10:10 AM 35b. License No. NE 26128 Approximate Interval: Onset To Death A)1 DAY 13)20 YEARS C) D) 29b. Autopsy Findings Available To Complete The Cause Of Death 29c. Coroner Contacted YES 32. Mariner Of Death NATURAL 33f. Location (Street And Number Or Rural Route, City Or Town, State, And Zip Code) 34c. Actual Or Presumed Time Of Death 10:10 AM 35c. Date Certified 11/27/2018 94d. Name Of Person Pronouncing Death 35d. Address And Zip Code Of Person Completing Cause Of Death 729 N CUSTER AVE, GRAND ISLAND, NEBRASKA, 68803 34e. License No.