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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Lanny Boyd Bundy 2. SEX ` Male ' 3. PATE OF t#2AIHIMO,. Day, Yr.) - July 9, 2013 -, - 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Scotia, Nebraska 5a. AGE - Last Birthday (Yrs.) 69 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE''OF BIRTH (Mo., Day, Yr.) September 22, 1943 MOS. I DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -56 -0109 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (lf not Institution, give street and number) Saint Francis Medical Center ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH I Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall I 9c. CITY OR TOWN I Grand Island 9d. STREET AND NUMBER 2407 Apache Road e. APT. NO. r 9f. ZIP CODE 68801 9g. INSIDE CITY (JMrFS I ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Shirley Cetak 11. FATHER'S -NAME (First, Middle, Last, Suffix) Obediah Boyd Bundy 12. MOTHER'S -NAME (First, Middle, . Malden Surname) Mildred Viola Layher 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Shirley Bundy 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSmON ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) July 10, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Ord Memorial Chapel, Inc., 1005 North 28th Street, PO Box 230, Ord, Nebraska 17b. Zip Code 68862 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART I. Enter the grain of events - diseases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death 1 Day respiratory west, 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) Respiratory Failure disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Cardiac Arrest 1 Day any, lading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) Acute Anemia, Suspected Infra Abdominal Hemorrhage 1 Day (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART L Liver Masses 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death 1:1 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ID Suicide ❑Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. 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 b' 1 E )( 23a. DATE OF DEATH (Mo., Day, Yr.) July 9, 2013 �' g E ). I 1 0 ) - E < 21 N 8 W z . 2 G ~ o s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) July 10, 2013 23c. TIME OF DEATH 07:45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 t 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 3 and due to the cause(s) stated. (Signature and Titre) 2 Isaac J. Berg, MD 24e. On the heals of examination and/or Investigation, in my opinion death occurred at the time, date and place and due to the auee(s) sta (Signature and Tkle) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES El NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE /1+• /� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I July 11, 2013 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND N SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,DEP ,OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE STATE OF NEBRASKA 07/24/2013 20 13 0 6 4 21 STANLEY S. cOOP.E a. t.. ' i S;'tTAN t$,TATE REGIS T 4, , DE.`PARTMEVt OF HEALTH ANDr. LINCOLN, NEBRASKA HUMAN. SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES'. CERTIFICATE OF DEATH 3 02949