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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) John Andrew Brunken 2. SEX Male 3. DATE OFDEATH (Mo., Day, Yr.) . February 20, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Adams County, Nebraska 5a. AGE - Last Birthday (Yrs.) 84 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) September 24, 1929 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -32 -9061 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing HomeILTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Grand Island Veterans Home ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Doniphan 9d. STREET AND NUMBER 209 E. Plum 9e. APT. NO. 9f. ZIP CODE I 68832 9g. INSIDE CITY LIMITS ® 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 Jeanine Louise Weavers 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Brunken 12. MOTHER'S -NAME (First, Middle, Malden Surname) Silbedeena Eyten 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 02/20/1951- 01/30/1953 14a. INFORMANT -NAME Jeanine Louise Brunken 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE T Katie M. Ewald 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) February 25, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Cedarview Cemetery Doniphan Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 18. PART 1. Enter the chain 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 Year respiratory arrest, 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) Parkinson's Disease. disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) any, leading to the cause listed on line 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 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the d - -- ` but not resulting In the underlying cause given in PART I. Coronary Artery Disease; Chronic Obstructive Pulmonary Disease. 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 ❑ 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 lion ❑ Suicide ❑ Could 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 construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE W i E } E w i 23a. DATE OF DEATH (Mo., Day, Yr.) February 20, 2014 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) February 21, 2014 23c. TIME OF DEATH 11:25 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 i-1 O 3d. To the best of my knowledge, death occurred at the time, date and place o c and due to the cause(s) stated. (Signature and Title) Gene L. Wyse, DO 24e. On the basis of examination and /or Investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? YES Ott NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO AME, TITLE AND ADDRESS OF CERTIFIER (Type or Print$ Gene L. Wyse, DO, 2300 West Capital Avenue, Grand Island, Nebraska, 68803 i 8a. REGISTRAR'S SIGNATURE 1 5 � - ` - _ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I February 24, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTW,'AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAS fA,DEPARTMENT'OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORD$. STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVi *0 CERTIFICATE OF DEATH DATE OF ISSUANCE 02/27/2014 231 40 4 9 1 2 STANLEY, . OPEIZ ASSISTANT'S E6ISTl f}R. DEPARTMENT IDF IlEAf.TH AND LINCOLN, NEBRASKA HUMAN SERVICES 14 00893