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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 09/15/2011 201902936 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES _ STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 11 03031 To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Rodney Hugo Harders 2. SEX Male 3.VATE-OF DEATH (Mo., Day, Yr.) September 1, 2011 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.) Wood River, Nebraska (Yrs.) 78 MOS. DAYS HOURS MINS. November 16, 1932 7. SOCIAL SECURITY NUMBER 505-48-9684 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical 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 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Howard 9c. CITY OR TOWN Boelus 9d. STREET AND NUMBER 675 Yutan Road 9e. APT. NO. 9f. ZIP CODE 68820 9g. INSIDE CITY LIMITS 0 YES E NO 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated 0 Widowed 0 Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name Norma Jean Mahurin 11. FATHER'S -NAME (First, Middle, Last, Suffix) Hugo Harders 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Clara Amanda Kroeger 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) Yes 01/08/1953-12/10/1954 14a. INFORMANT -NAME Norma Jean Harders 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION E Burial 0 Donation 16a. EMBALMER -SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) September 6, 2011 ❑ Cremation ❑Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. 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 line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting onset to death 3 Weeks in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Pneumonia any, leading to the cause listed onset to death on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Depression (disease 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 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I. Acute Renal Failure, Ileus, COPD, Coronary Artery Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES E NO 0. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH E Natural 0 Homicide 0 Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO leted by: C ❑❑❑1 c z z R o 0 OO a a a � 5 z a o- 1 m a o o 0 t u a It Ya o n •c m w v n 0 0 0 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 To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) September 1, 2011 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.) September 13, 2011 23c. TIME OF DEATH 10:30 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) Jane A. McDonald, MD 24e. On the basis of examination and/or investig tion, 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 E NO 0 PROBABLY 0 UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, Jane A. McDonald, MD, 800 N Alpha Street, G 26a. HAS ORGAN OR 0 YES ISSUE DONATION BEEN CONSIDERED? /7 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO HYSICIAN ASSISTANT CORONER'S PHYSICIAN OR COUNTY A and Island, Nebra ka, .:: ORNEY) (Type or Print) j28a. REGISTRAR'S SIGNATURE dej _ ! 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I September 14, 2011 Exhibit "A"