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STATE OF NEBRASKA 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 12/15/2017 LINCOLN, NEBRASKA 201905004 Cao STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Richard Ralph Andresen 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) December 8, 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.) Minneapolis, Minnesota (Yrs.) 71 MOS. DAYS HOURS MINS. July 10, 1946 7. SOCIAL SECURITY NUMBER 469-52-1302 8a. PLACE OF DEATH HOSPITAL El Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility . FACILITY-f:AME (If nM Institution, give street and number) CHI Health St. Francis 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 4610 Lakeside Dr. 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 ❑ Marded, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Donna Rae Pearsall 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ralph Edward Andresen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mildred Cordelia Weiseth 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No. or Unk.) Yes 09/04/1968-09/03/1972 148. INFORMANT -NAME Donna Rae Andresen 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ serial 0 Donation 16a. EMBALMER -SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) December 13, 2017 ® Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon 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 17b. Zip Code 68801 1 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 48. 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: IMMEDIATECAUSE(Final a)Thrombocytopenia, Progressive Deep Venous Thrombosis, Pulmonary Embolism, Hypoxia disease or condition resulting onset to death 72 Hours n death] DUE TO, OR AS A CONSEQUENCE OF: Sequentially Int conditions, if 4 b) any, leading to the Cause (feted onset to death on linea. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated' onset to death Me events resulting,m 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 1. History Of Hypertension, Hyperlipidemia, History Of Bladder Cancer, History Of Closed Head Injury 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Il 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 Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ENO 0 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 ❑ ❑ 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 ONO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8, NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 234. DATE OF DEATH (Mo.. :lay ; Yr.) December 8; 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.) December 11, 2017 23c. TIME OF DEATH 08:14 AM 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 and Title) Jane A. McDonald, MD 245. On the basis of examination and/or investiga ion, 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 0 UNKNOWN 26a. HAS ORGAN OR • • ATION BEEN CONSIDERED? 0 YES 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑YES ❑ 'NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska,68803 28a. REGISTRAR'S SIGNATURE /(- �) 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 12, 2017 (JJ -I CO