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EXHIBIT "A" WHEN THIS COPY CARDS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CER71FIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST►C,4 SiiAGH HIS THE LEGAL DEPOSITORY FOR VITAL RECORDS ` DATE OF ISSUANCE 6/21 /2004 200M091 Yom' xcooftw LINCOLN, NEBRASKA HEALTH AI 00110 3j3TEM- 4 STATE OF NEBRASKA- DF ARThEWT of HBALTH Arm HUMAN 0 06621 VffAL STATIST= CERTIFICATE OF DEATH -- I. DECEDENT -NAME FIRST MIDDLE LAST 2 SE7f..t ,'a; _ _ _ 'S DA'18OF TH /Mart. Day. Yearl William RUDD Male Jun 7 2004 4. CRY AND STATE OF BIRTH (Mnot it U.SA, name campy/ Sa. AGE -.Last Birthday UNDER 1 YEAR UNDER i DAY & DATE OF BIRTH (Mor& Day Ysarl MOS. DAYS Sa HOURS MINS Winnipeg, Canada (Y* S0. 90 Feb 19 1914 7. SOCIAL SECURTIY NUMBER - 9a PLACE OF DEATH 712 -05 -4686 HOSPITAL ® inpatient OTHER: Nursing Home ❑ ER. Outpatient Residence ❑ 8b. FACILITY - Name (MnotmaliMAyygmspeetmrdaxnhwl Saint Francis Medical Center ❑ DOA ❑ Other(specrly) 8C. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island Y. M. No ❑ Hail 9a RESIDENCE -STATE 9b. COUNTY 90. CITY, 7Oy11N;Qi1LOCATION 9Q STREET AND NUMBER pncludbgZld Code) 9e. INSIDE CITY LIMITS Nebraska Hall Grand .Island 1404 'Woodland Dr. 078.68801 Yee ❑X No ❑ 10. RACE - (a4, White, Black. American Wan. 11. ANCESTRY (e.g.. Italian. Mexican, German, etc} 12 ® MARRIED. ❑ WIDOWED 13. NAME OF.SPOUSE (N wile. give maiden name/ . et.) (Specify) White (Sp") German NEVER DIVORCED Maxine Hann CCUPATION /Give kind of work done d #kV ~ 14b. KIND OF BUSINESS INDUSTRY !ATI 15. EDUCATION (Specily only highest grade completed( g kb. scan i/rekred/ Secondary (0-121 College 12 or 5 -1 r erator 1 2 NAME FIRST MIDDLE T 17. MOTHER FIRST MIDDLE MAIDEN SURNAME L14aUSUAL Hen Ru Amelia Weber EASED EVER IN U.S. ARMED FORCES? . � 19a INFORMANT - NAME wk1 III yes. give war aa1 does of services! 1106 30 1943 11/19/19431' 1 19 1943 Maxine K. Rupp 19b. INFORMANT MAILING ADDRESS - (STREET OR R.F.D. NO.; CRY OR TOWN. STATE. ZIP) _ 404 Woodland Dr. #78 Grand Island NE 68801 20.E - SIGNATURE 6. 21 a METHOD OF DISPOSITION 21 h, DATE 21 C. CEMETERY OR CREMATORY - NAME > 10 92 Burial ❑ Ram, w Jun 10, 2004 Grand Island City ' 22a FUNERALL HOME -NAME I 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE ❑Q ii." ❑°°"a°°" Curran Funeral Chapel 3168 W. Stolle Park Rd. Grand Island NE 22b, FUNERAL HOME ADDRESS . ISTREET OR-R.F.D. NO.. CITY OR TOWN. STATE ZIP) 3005 South Locust Street Grand Island NE 68801 IMM TE,,CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). 1b), AND (c)) Interval between o and death P ` , • ^ I () V. V \ IN \ 1 \�V \ DUE TO, OR AS JCONSEQUENCE OF: Inerval between onset and death rot DUE TO. OR AS A CONSEOUENCE OF: I kaeNal between onset and death I (c) i I PART OTHER SIGNIFICANT CONDITIONS - CorWiliar conkft rg lo the death but nW ralaed PARTAI IF FEMALE WAS THERE A 24. AUTOPSY M. WAS CASE REFERRED TO MEDICAL PREGNANCY e IN THE PAST 3 MONTHS? EXAMINER OR CORONER? (Ages 10-541 Yea No Yes No Yes No 28a. 280. DATE OF INJURY (W Day. 114) 25c. HOUR OF INJURY 28d DESCRIBE HOW INJURY OCCURRED . ❑ Accident El Undetermined 1 M ❑ Suicide ❑ Pendirig 289. INJURY AT WORK 28f. PLACE FFIN INJURY - N h,me, farm, meet factory o�x DuM /SpecaY) 28g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE ❑ Homicide Inman Y. ❑ No ❑ a DATE OF DEATH (Ada- Day. Yr.) 28a. DATE SIGNED (Ab.. Day. Yrl 28b. TIME OF DEATH v V ` \ M DA'TE SIGNED (MO- Day. Yr.) ME OF DEATH 2Bc. PRONOUNCED DEAD /MO.. Day, Yc) 2ed. PRONOUNCED DEAD (Hour) our) E .t\\ 1 ` �vo Q O \ M s r- v 0. To the best of my curred at the a, and pace to the 28e. On the basis of exammatlon ands Investigation, m ' my opinion death occurred at cause(s) seed - a � �, o b the arms, oleo and pace and due to the calee(s! staled. cause(s) - and Title ► t \ • `�••• . rr` aan and TMel ► . 010 TOBACCO USE CONTRIBUTE TO THE DEATH? HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? WAS CONSENT GRANTED? ❑ YES g NO ❑ UNKNOWN ❑ YES 5kNO ❑ YES 31. NAME AND ADDRESS OF CERTIFIER (PHYSCUN, OORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type orPdnt) John J. Cannella M.D. 729 X. Custer AV Grand Island NE 68803 32a REGISTRAR. 320. DATE FILED BY REGISTRAR (W.., Day Yr.) JUN 18 2004 U -