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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Robert Lyle Bruhn 2. SEX Male 3, DATE OF DEATH (Mo., Day, Yr.) August 7, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE • Last Birthday (Yrs.) 78 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) August 7, 1935 MOS. I DAYS HOURS MMIS. I 7. SOCIAL SECURITY NUMBER 507 -42 -2608 8b. FACILITY -NAME (If not Institution, give street and number) 2430 North Custer Avenue 8a. PLACE OF DEATH MPITAL ❑ inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 88803 I 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall ac. CITY OR TOWN f Grand Island 8d. STREET AND NUMBER 2430 North Custer Avenue APT. NO. 9f. ZIP CODE I 68803 I 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name Shirley Ann Woodruff 11. FATHER'S -NAME (First, Middle, Last, Suffix) Dale Carl Lewis Bruhn 12. MOTHER'S -NAME (First, Middle, Malden Surname) Mina Bernice Barnard 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 04/09/1958- 01/13/1961 14a. INFORMANT -NAME Shirley Ann Bruhn 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Tracey Dietz 18b. LICENSE NO. 1328 16c. DATE (Mo., Day, Yr.) August 10, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 15. PART I. Enter the chain of events- diseases, Injuries, or complicationathat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL only one cause on a line. Add additional lines if necessary. onset to death Weeks respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Coronary Artery Disease disease or condition retuning in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially Het conditions, If b) any, leading to the cause listed on tine a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (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!. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ill NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ 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 Suicide Coultl not be determined ❑ l 22c. PLACE OF INJURY -At home, 21b. IF TRANSPORTATION INJURY ❑ Ddver/Operator ❑ Passenger Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY farm, street, factory, office building, 22d. INJURY AT WORK? DYES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE S 5 1 23a. DATE OF DEATH (Mo., Day, Yr.) August 7, 2013 11 i < o W .8 12 o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED 8 (Mo., Day, Yr.) A , 2013 23c. TIME OF DEATH I 09: 50 AM 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD d. To occurred tlw best of my knowledge, death occurred at the time, dab and play E and due to the cause(s) stated. (Signature and Title) g Travis S. Hageman, MD es cause(s) Title) 24e. On the basis of examination and/or investigation, In my opinion death occurred at a the time, data and place and due to the use(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSU D ONATION BEEN CONSIDERED? ❑ YES ® NO 28b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO 0 YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 iii 28a. REGISTRAR'S SIGNATURE , V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 9, 2013 DATE OF ISSUANCE 08/12/2013 LINCOLN, NEBRASKA STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE 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. " 201309321 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVI CERTIFICATE OF DEATH STANLEY S COOPER ASSIS3ANT DEPAR ND HUMAN 13 03380