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Exhibit A STATE OF NEBRASKA e �J WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORD -ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISM$ -SMT 0)V, ICH IS THE LEGAL. DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE A1iILL:Y -s. COOPwR A"sSW -_ ANT STATE REGISTRAR LINCOLN, NL�BRASKA 200508768 146 TIfAND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT - n CERTIFICATE OF DEATH 05 09015 1. DECEDENT'S•NAME (First, Middle, Last, Suffix) 2, SEX 3. DATE OF DEATH (Mo.. Day, Yr.) __._.Robert _.., F t..11,.._.20Q- 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 58. AGE -Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY S. DATE OF BIRTH (Mo.. Day, Yr) (Yrs.) MOS. DAYS HOURS MIN$. Amherst, Nebraska 85 January 25, 1920 7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH 720 -03 -5249 HDS.PJTAL: ❑ Inpatient l)1�{ER: N Nursing Home/LTC ❑Hospice Facility .. .. ........-- - - --- 8b. FACILITY -NAME (If not Institution, give street and number) El ❑ Decedent's Home Veterans Affairs Medical Center ER/Outpatient 2201 N. Broadwell ❑ DD, ❑ Other($pecify) Be. CITY OR TOWN OF DEATH (include ZIP Code) Bd COUNTY OF DEATH Grand Island_ 68803 9a. RESIDENCE -STATE 9b, COUNTY 9c. CITY OR TOWN Nebraska Hall Grand Island 9d. STREET AND NUMBER ge. APT. NO 9f. ZIP CODE 99. INSIDE CITY LIMITS 2309 W. Anna S t . 68803 LX YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH M Married ❑ Never Married tub. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. ❑ Married, but separated ❑Widowed ❑Divorced ❑ 11b is n Unknown Loucille�- 11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'S,NAME (First, Middle, Maiden Surname) Fred Riessland Gertrude Ripp 13. EVER IN V,S. ARMED FORCES? Give dates of service II yes. 14a. INFORMANT -NAME 141b. RELATIONSHIP TO DECEDENT (Yes, no, orunk.) -10-13-45 LoucilleRiessland _ _ Wife - ..... - - -Ia_ IS, METHOD OF DISPOSITION 16a. IGIN TUR n 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr, } LYZurlal ❑Donation Aug. 15, 2005 Cl Cremation LJEntombment 16d. CEMETERY, 01MATIRI .RR LOCATION CITY /TOWN STATE El Removal El Other (Specify) Ft. McPherson National Cemetery Maxwell, Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b, ZIP Code Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island, NF 1 68803 18. PART 1. Enter the Chain of evenly -- diseases, injuries, or complications•dhat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL I respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enteronly one cause on a line. Add additional lines If necessary. I IMMEDIATE CAUSE: I onset io death IMMEDIATE CAUSE ( Final aCa_ r io -Rasp r..a t- -xy Failure - - -- I L ew Minutes disease orcondition resulting DUE T0, OR AS A CONSEQUENCE OF: I onset le death indeath) Sequentially list conditions, If (b)End Stage COPD (Palliative Care) Several Years any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF; I onset to death on line a. 24d.TIMIEPRONOUNCEDUEAD Enter the UNDERLYING CAUSE Au August 12 2005 (disease or Injury that Initiated MAspira.tion Pneumonia r1 the events resulting In death) -- -._...... _._. -. _.----- ........ - ._ ---.. ..... DUE T0, OR AS A CONSEQUENCE OF _.._....._1_G_nayS I onset to death LAST (d) Dehydration Few Days 18, PART 11.OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 23d.To the best of my knowledge, death occurred at the time, date and place 19, WAS MEDICAL EXAMINER m` and due to the cause(s) slated. (Signature anr�Title) T OR CORONER CONTACTED? Hypoxi.a, Anorexia r „ y, Li YES -M NO 20. IF FEMALE: 21....,.............-- a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? L] Not pregnant within past year N Natural ❑ Homicide El Driver /Operator Ll "K1 CJ Pregnant at time of death ❑Accident❑ Pending Investigation ❑ Passenger YES NO ❑ Not pregnant, but pregnant within 42 days of death ❑ Suicide Q Could not be determined LJ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Other (Specify) COMPLETE CAUSE OF DEATH? ❑ Unknown It pregnant wlthln the past year ❑ YES Ll 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) 22e. DESCRIBE HOW INJURY OCCURRED 22d. INJURY ATWO13KI ❑ YES ❑ NO r ......... ..........--- -._......__...... .. 221. LOCATION OF INJURY - STREET RNUMBER. APT NO, CITYJrOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH .�i Aupust 11, 2005 A M Li (n 23b.DAATESIGNED(Mo.,Day,Yr,) 230, TIME OF DEATH � 24c.PRONOUNCEDbEAb(Mo.,Day,Yr.) 24d.TIMIEPRONOUNCEDUEAD Paz Au August 12 2005 1:00 m �4= m U.S ST 23d.To the best of my knowledge, death occurred at the time, date and place 0 z 24e. On the basis of examination and/or Investlgallon. In my opinlon death occurred at m` and due to the cause(s) slated. (Signature anr�Title) T .8 G p the time, date and place and due to the cause(s) stated. (Signature and Title ) FIS r „ y, FD f2YU 25.DIDTOBA000 USECONTRIBUTETOTHE DEATH? 26a.HA$ ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES ❑ NO LKPROBABLY U UNKNOWN ail YES U NO Not Applicable if 26a is NO U YES ! NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Neena Biswas MD Nebraska Western Iowa HCS 2201 N. Broadwell Grand Island IM 6880 28a. REGISTRAR'S SIGNATURE A(O& i 28b. DATE FILED BY REGISTRAR (MO., Day, Yr.) AUG 16 2005