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iR Awia% tQl y 4 0 InAA , 4161i L UAJIAA A /4a STATE OF NEBRASKA .:... .. s U wwwwwr W U 0 U s't 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ann Eileen Bruns 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 7. SOCIAL SECURITY NUMBER 505 -02 -1446 84. FACILITY -NAME Whet Institution, give street and number) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 g as RESIDENCE -STATE 9b. COUNTY Nebraska Hall 9d. STREET AND NUMBER 1311 N. Geddes St. 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, butseparated 'g ❑ Widowed ❑ Divorced ❑ Unknown 1 1. FATHER'S -NAME (First, Middle, Last, Suffix) Robert William Moore 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No or link.) No 1 5. METHOOOF DISPOSITION 16a. EMBALMER- SIGNATURE ❑ Burial ❑ Donation Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) Central Nebraska Cremation Services 1 7a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska Spalding, Nebraska 1311 N. Geddes St:' CAUSE OF DEATHJSee instructions and examples) PART 1. Enter the Chain of events- - diseases, injuries, or complications -that directly caused the death, DO NOT entertenninat events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one dense on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Metastatic Sarcoma, Of Left Thigh disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list COndniohs, if . j b) any, leading to the cause tisted � on line a. Enter the UNDERLYING CAUSE (disease dr injury that initiated.. the eVentsresahing m death) LAST: 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. FEMALE; pregnant withm past year ❑ Pregnant at time of death __❑ Not pregnant, put pregnant within 42 days of tleath ❑ Not pregnant, but pregttafint 43 days to 1 year before death ❑Unknown if #regnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) I 22b. TI ME OF INJURY 22d. INJURY AT WORK? I 22e. DESCRIBE HOW INJURY OCCURRED [3 YES ❑ NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. WHEN.. T f COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 DATE OF ISSUANCE 7/1/2016 LINCOLN, NEBRASKA 23a. DATE QF DEATH (Mo., Day, Yr.) June It 20:16 3b. DATE SIGNED (Mo., Day, Yr.) • 28e. REGISTRAR'S SIGNATURE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 23c. TIME OF DEATH 02:19 AM June 29 "2016 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Travis S. Hageman, MD 201604469 5a, AGE - Last B(tthday (Yrs.) 14a. INFORMANT -NAME Dennis Wayne Bruns 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide Could not be deterrnmed CITY /TOWN 54 b. UNDER 1YEAR MOS. DAYS 8a. PLACE OF DEATH HOSPITAL 0 Inpatient 0 ER/Outpatient 0 DOA 1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Dennis Wayne Bruns 1 i12. MOTHER'S -NAME (First, Middle, Maiden Surname) Elizabeth Josephine Clark 1 22c. PLACE OF INJURY -At home, f 8c. CITY OR TOWN Grand Island 9e. APT. NO. HOURS 16tt, LICENSE NO. STANLEY S.' COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Female 8d. COUNTY OF DEATH Hall CITY / TOWN Gibbon 5c. UNDER 1 DAY MINS. OTHER ❑ Nursing Home /LTC E Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68801 21b. IF TRANSPORTATION INJURY - I ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) STATE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr. 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES <® NO 0 PROBABLY ❑ UNKNOWN ❑ YES ENO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 h, aye February 14, 11 16 036 3. DATE OF DEATH (Mo., Day, Yr.) June 16, 2016 6. DATE OF BIRTH (Mo., Day, Y 2 ❑ Hospice Facility 9g. INSIDE CITY LIMITS ❑ YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Husband .. 16c. DATE (Mo., Day, Yr.) June 18, 2016 STATE Nebraska 1 .17b;:•zio.pode 68801 AppRoMMAW INT ERVAL, onset to death • Years onset to death rm,'street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH 24d. TIME PRONOUNCED D 24e. On the basis of examination andlor investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) onset to death. onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ?' ❑ YES I NO 21d. WERE AUTOPSY FINDINGS AVAILABL _ TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO ZIP COD E;'. 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mo,, Day, Yr4 June 29, 2016