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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.' A. 6" _ _ " DATE OF ISSUANCE JUL 112011 LINCOLN, NEBRASKA STATE OF NEBRASKA s 20140755. STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH, STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES 11 25633 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Ralph Ray Bruns 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) June 23, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Palmer Nebraska 5a. AGE -Last Birthday (Yrs.) -, 62 . 5b. UNDER 1 YEAR 5c, UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 25, 1949 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -62 -4428 8a. PLACE Or DEATH nospiTAI.: C Inpatient OTHER: ❑ Nursing Home /LTC ❑ Hospice Facility t ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) ' - 8b. FACILITY -NAME (If not institution, give street and number) St. Francis Medical Center 80. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall M1Nbf 3z dnlo3 eg q 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 3036 Goldenrod Drive 9e. APT. NO 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS 53 YES ❑ NO 105. MARITAL STATUS AT TIME OF DEATH XI Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Kay Lynn Nelson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harvey William Bruns 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Merle Grace Kaiser 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes, no, or unk.) No 14a. INFORMANT -NAME Kay L. Bruns 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION $1 Burial ❑ Donation [a Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER•SIGNAT E A„,94_0,... ,va, 16b. LICENSE N0. 1078 16c. DATE (MO., Day, Yr. ) June 28, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Zion Lutheran Cemetery Worms, Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Peters Funeral Home, Inc P.O. Box 181 St. Paul NE 176. Zip Code c 68873 GA E Ofi► �Seflititt$tuatiatB i ifd e� mple z Tope Canpletod by;�fRf1F1 18. PART I. Enter the chain of events - diseases, injuries, or complications - -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, I APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. j IMMEDIATE CAUSE: I onset to death 1 IMMEDIATE CAUSE (Final (a) C,0,1 p1F\ nno V1( r1 iC-S-k ,1^/i m 2Ut G A disease or condition resulting DUE TO, OR AS A CON EQUENCE OF: I ' onset to death In death) I Sequentially list conditions, (b) it any, leading to the cause DUE TO, OR AS A CONSEQUENCE OF: I onset to death listed on line a. Enter the UNDERLYING (c) CAUSE (disease or injury that DUE TO, OR AS A CONSEQUENCE OF: i onset to death initiated the events resulting in death) LAST (d) I I 18. PART II. OTHER SIGNIFICANT CONDITIONS•Conditions contributing to the resulting in the underlying cause given in PART I. 8 I■S •y c- p Si - - a 4- e C L t'1 t 'Th:WAS MEDICAL EXAMINER OR CORONER CONTACTED? lif YES 471110 20. IF FEMALE: Q Not pregnant within past year L:1 Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days 101 year before death ❑ ' Unknown if pregnant within the past year :13ta. MANNER XNaturl e ❑ Accident Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY 01 Driverl0perator ❑ Passenger ❑ Pedestrian ❑Other (Specify) SIC. WAS AN AUTOPSY PERFORMED? �t ❑ YES �NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO uction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr,) [22b. TIME OF INJURY 122c. 1 m l PLACE OF INJURY -At home, farm, street, factory, office building, cons) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE a LL t 23b. o „w ?.1 u U 2 [i H� 23a. DATE OF DEATH (Mo.. Day. Yr.) 24a : DATE SICINFn (Mo., Day, Yr.) 0110 bi 1 L. 24b, TIME OF DEATH a, 1 4 (11'.IA- pm) 244. TIME PRONOUNCED DEAD i I t (_AAc,)m DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH m npleted s PHYSI f ATTOI VLY 244L NCED DE D (Mo., Day, Yr.) Ck1.9.31 23d. To the best of my knowledge, death occur ed at the time, date and place and due to the cause(s) stated. (Signatu e and Title) • 4 0n the basis of ex urination the time, date and place and andlor Ines igation, in my opinion death occurred at due to the cause(s) stated. (Signature and Title ) • -25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY d UNKNOWN `28a. HAS ORGAN OR TISSUE DONATION BEEN C SIDERED? ❑ YES gyp, NO 28b. WAS CONSENT GRANTED? Not Applicable if 26a is no ❑ YES ❑ NO 21. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUN ATTOR (Type or�rintd co-- � y A N >,r � NI . eCLA - Sc)nE') I ,^ P , , v y hrall OJ� ,� I' Y e0 P t X6 , x■ 41Ci vTr \ , Nr Zo��U1� 11 28a. REGISTRAR'S SIGNATURE - 1r ,Q. U1i 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) JUL 8 2011 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.' A. 6" _ _ " DATE OF ISSUANCE JUL 112011 LINCOLN, NEBRASKA STATE OF NEBRASKA s 20140755. STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH, STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES 11 25633