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EXHIBIT "A" WHEN THIS COPYCAMWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEIK IT CERTMS THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. - DATE OF ISSUANCE_ AI i g =0PER 6/28/2004 ' fSTRAR LINCOLN, NEBRASKA HEALTH TEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES $ ANDSUgPORT VITAL STATISTICS - `4 06960 CERTIFICATE OF DEA i'fK: 1. DECEDENT -NAME FIRST MIDDLE LAST ' 2..SEX., ;.,- - -'=:`= 7 /SATE OF DEATH /Month. Day. Year) Arthur John Papke Ma.11e June 22, 2004 4. CITY AND STATE OF BIRTH (ft not in U.S.A.. name country/ 5a. AGE -Last Birthday I UNDER 1 YEAR t UNDER 1 DAY -' 6. DATE OF BIRTH /Month. Day. Year) Omaha, Nebraska (Yr5.) 83 5b. O MOS.I DAYS 5c. HOURS "' Mil May 6, 1921 7. SOCIAL SECURTIY NUMBER Be. PLACE OF DEATH 508 -30 -3367 HOSPITAL: Inpatient OTHER: Nursing Home - -.- ❑ ❑ ER Outpatient ® Residence 8b. FACILITY - Name (ffrotrnshtulion, give sheet and number/ 309 East 7th St. ❑ DOA ❑ Other (Specito 8c. CITY, TOWN OR LOCATION OF DEATH - 8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island Y. N] Nd ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Code) 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 1309 E. 7th St. 68801 X❑ ❑ Yes No 10. RACE - (e.g., White. Black. American Indian, 11. ANCESTRY (e.g.. Italian, Mexican, German, etc) 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE (If wile. give maiden name) etc.) (Specify) White (Specify) American NEVER DIVORCED Wilma Scheer MARRI 14a. USUAL OCCUPATION /Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION )Specify only highest grade completed) of working life, even dretrred) Refrigeration repair Owner /Operator Elementary or Secondary 10 -121 College 11 -4 or 5.1 10 16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Arthur John Papke Thelma D. Tingley 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yes. no. or unk.) 18 yes. give war and dates of services) Yes 8/7%1942 - 11/5/1945 HIM Wilma Papke 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 309 E. 7th St., Grand Island, Nebraska 68801 20. BALMER - GN TURE &jJj N_SE NOO. 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME y "r A 10 7 1 1A Burial ❑ Removal June 26 2004 wn MEm Paxk Cemetery a. FUNERAL HOME - NAME _ 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE All Faiths Funeral Home 11 Cremation ❑Donation Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 2929 S. Locust St., Grand Island, Nebraska 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lat. (b). AND (c)) I Interval between onset and death PART al G. S I � tr y1 • DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death (b) e4-l1 krNrOW S O�S � II rIf-S DUE TO. OR AS A CONSEQUENCE OF Interval between onset and death I lcl I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25, WAS CASE REFERRED TO MEDICAL PREGNANCY II IN THE PAST 3 MONTHS? EXAMINER OR CORONER? (Ages 10 -541 Yes No 0 Yes No Yes No 26a. 26b. DATE OF INJURY (Mo.. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJJRY OCCURRED 1-1 Accident ❑ Undefermined M El Suicide ❑ Pending 26e. INJURY AT WORK 26f. PLACE OF INJURY - At home, farm. street. factory ce budding. etc. (Specify) 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE ❑ Homicide Investigation Yes No El No 27a. DATE OF DEATH /Mo.. Day. Yr.) 28a. DATE SIGNED (MO.. Day. Yr.) 28b. TIME OF DEATH �a June 22, 2004 �,I M 1� .1 s } 27b. DATE SIGNED /MO.. Day. Yr.) 27c, TIME OF DEATH 28c. PRONOUNCED DEAD /Mo.. Day. Yr) 28d. PRONOUNCED DEAD /Hour) �} 6 8:00 A. M ¢� M 8'2 Sze 27d. To the best 0f my knowledg at a 'me, date a ce and due to the 28e. On the basis of examination and,or investigation, in my opinion death occurred at a ° ~ 90 causelsl stated. \Ye the time, date and place and due to the causelsl stated. Jloccurred (Si nature and Title) 0 I - lSi nature and Title ► 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES � NO UNKNOWN ❑ YES I �4 NO N: YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pnnt) David Colan, M.D., 729 N. Custer Ave., Grand Island NE 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo., Day. Yr.) JUN 2 5 2004 - -/, - - -0