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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. 01' DATE OF ISSUANCE 02/19/2014 LINCOLN, NEBRASKA 20150137G 2019047'30 STANLEY S COOPER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 14 00756 To be completedNerified by: FUNERAL DIRECTOR I 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Gerald Dean Frederiksen 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) February 12, 2014 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.) Merrick County, Nebraska (Yrs.) 85 MOS. DAYS HOURS MINS. May 27, 1928 7. SOCIAL SECURITY NUMBER 550-32-1898 8a. PLACE OF DEATH HOSPITAL E Inpatient OTHER ❑ 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 Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 680 S Shady Bend Road 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married ❑ Married. but separated ❑ Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name June Eastman 11. FATHER'S -NAME (First, Middle, Last, Suffix) Guy Frederiksen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mabel Heinemann 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 06/23/1954-06/21/1956 14a. INFORMANT -NAME June Frederiksen 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Mike McQuiston 16b. LICENSE NO. 1129 16c. DATE (Mo., Day, Yr.) February 17, 2014 ❑ Cremation ❑Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Giltner Cemetery Giltner Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Higby McQuiston Mortuary, Inc., 1404 L Street, PO Box 204, Aurora, Nebraska 17b. Zip Code 68818 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) Sepsis disease or condition resulting onset to death 3 Days In death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Diffuse Vascular Disease any, leading to the cause listed onset to death online a. 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 to 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 ENO 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 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ENO ❑ 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 ❑ 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 mpleted CERTIFIER VLY 23a. DATE OF DEATH (Mc., Day, Yr.) February 12, 2014 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.) February 17, 2014 23c. TIME OF DEATH 01:41 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature nd Title) Richard Fruehling, 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? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES 0 NO 0 PROBABLY 0 UNKNOWN 0 YES E 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 Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE j6 c _- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I February 18, 2014