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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 FO R vizarqz.Emeto,s, DATE OF ISSUANCE r ! 08/19/2014 201_502239 5T1UE>t bbPt, �� ,;A,SBISTANT STALE REGIS - 3%4, ,C R OF HEALTH AND", LINCOLN, NEBRASKA ` ; I MANsS VI C HEALTH • Eli • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANt,SE9YICES ) ` r 14 04042 CERTIFICATE OF DEATH L1 4d 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ronald Gene Brabander 2.1Ex, ••` (fir MLIl 1; • . •' pA:tp OF,DEATH(Mo., Day, Yr.) ' ;AugL10412 014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yre•) 70 5b. UNDER 1 YEAR 5c. UNDE1l t DAY- 6. "DATE OF BIRTH (Mo., Day, Yr.) y '" �. ` February 13, 1944 MOS. DAYS HOURS MIN'S 7. SOCIAL SECURITY NUMBER 508 -52 -0109 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSPITAL. ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility El ERlOutpatient ❑ 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 Grand Island 9d. STREET AND NUMBER 19e. APT. NO. 19f. 4015 Anne Marie Ave. I ZIP CODE 68803 19g. 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) 11 wife, give maiden name Margeret Ann Fruit 11. FATHER'S -NAME (First, Middle, Last, Suffix) Lyle Eugene Brabander 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Anita Mae Matthiesen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 1962 -1966 14a. INFORMANT -NAME Margeret Ann Brabander 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.) August 14, 2014 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) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 15. 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, r 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. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest disease or condition resulting onset to death Minutes In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Cardiac Event, NOS 1 Minutes any, leading to the cause listed I 1 on sine a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated 1 the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: r onset to death LAST d) I 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® 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 ❑ 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 I' I I re p- E Z 23a. DATE OF DEATH (Mo., Day, Yr.) k 1 i Q Y E W B i 3 a 24a. DATE SIGNED (Mo., Day, Yr.) August 14, 2014 24b. TIME OF DEATH Approx. 08:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) 123e. TIME OF DEATH 1 24c. PRONOUNCED DEAD (Mo., Day, Yr.) August 12, 2014 24d. TIME PRONOUNCED DEAD 08:43 AM g 0 0 2d. To the best of my knowledge, death occurred at Me time, date and place o u and due to the cause(*) stated. (Signature and Title) 24e. On the basis of examination and /or investigation in my opinion death occurred at Nancy Berger- Schneider, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR ❑ YES DONATION BEEN CONSIDERED? i7 NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Nancy Berger- Schneider, Hall Deputy County Attorney, 231 S. Lo P.O. Box 367, Grand Island, Nebraska, 68802 1280 REGISTRAR'S SIGNATURE ij - / 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 14, 2014 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 FO R vizarqz.Emeto,s, DATE OF ISSUANCE r ! 08/19/2014 201_502239 5T1UE>t bbPt, �� ,;A,SBISTANT STALE REGIS - 3%4, ,C R OF HEALTH AND", LINCOLN, NEBRASKA ` ; I MANsS VI C HEALTH • Eli • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANt,SE9YICES ) ` r 14 04042 CERTIFICATE OF DEATH L1 4d