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WHEN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFES Th E BELOW TO BE A TRUE COPY OF THE OR/GI sN-PKE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST/ SET N CH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE NOV 2 31999 200003806 = ° S.0 OIWR AS= --ANT STATE REGIST'Il LINCOLN, NEBRASKA HEALTHANd�HUMANBERVICFSiSV4EM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMANSWVICES FIN i00 SUPPORT VITAL STATISTICS -- - -- CERTIFICATE OF DEATH I DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH (Month. Day Yearl Albert Edward Brym Male November 16, 1999 4. CITY AND STATE OF BIRTH /Hriot n USA.. name country/ 5a. AGE -Last Birthday UNDER 1 YEAR UNDER I DAY 6. DATE OF BIRTH iMonth. Day Year) (Yrs.) 5b. MOS DAYS 5c. HOURS' MANS Dwight, Nebraska 90 May 22, 1909 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH 505 -10 -8861 HOSPITAL: ❑ Inpatient OTHER: © Nursing Home ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name (float rnstiluaorr, givestreetandnumberl St. Francis Skilled Care Center ❑ DOA ❑ Other fSpecrty' 8c. CITY TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS Be. . COUNTY OF DEATH Grand Island Y"19 ❑ I Hall 9a. RESIDENCE - STATE 9b, COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Code) 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 1719 West 14th.St. 68801 1 Yes ® No ❑ 10 RACE leg,. White. Black. American Indian. 11. ANCESTRY (e.g., Kahan. Mexican. German, etcl 12. ❑ MARRIED FXJ WIDOWED t 3. NAME OF SPOUSE (B wile. give maiden name/ etc .I(Soecityl Whit I IspMech /Bohemian MEVER DIVORCED Wilma C. Hoffbauer 14a USUAL OCCUPATION (Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION ISpecity only highest grade completed) _ Ele i�ti race ary ary 0 -121 College 11 -a or 5 -1 of working life, even it refired/ Carpet Installer Retail Carpet Sales It, FATHER - NAME FIRST MIDDLE UST 77 MOTHER FIRST MIDDLE MAIDEN SURNAME Anton J. Brym Anna NMN Shalon I; WAS OECEA.SEO EVER IN S. ARMED FORCES? 19a. INFORMANT NAME i res. no of unk.I I it ve5 give war and dates of services) No --- - - - - -- Donald Brym - Son I 19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 2520 S. Cochin, Grand Island, Nebraska 68801 20. BALMER - SIGNATURE & LICENSE 15� 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY,- NAME tNO� ® Burial ❑ Removal Nov. 20 1999- Westlawn Memorial Park . ita FUNERAL HOME NAME 21d CEMETERY OR CREMATORY LOCATiDN CITY OR TOWN STATE Livingston- Sondermann F.H. Creation ❑Donation ❑m Grand Island, Nebraska 22• _ FUNERAL HOME ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN. STATE, ZIP) 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 23 . IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (c)) I Interval between onset and death PART I 1 I k la) I +- DUE TO, OR AS A CONSECILIENCE OF Intery I between onset and deal I DUE TO. OR AS A CONSEQUENCE OF Infe vat between onset and death I (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 2a. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY II IN THE PAST 3 MONTHS? OR CORONER' - ' lMO (Ages 10 -541 Yes No Yes FI No yEXAMINER t Yes D No 26a 26b. DATE OF INJURY (Mo.. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Gr Accdenf ❑ Undetermined M u Suicide f Pending 26e. INJURY AT WORK 2 We E OFi INJURY Y . f> �l , larm, street. factory bu,ld SWC 26g. LOCATION STREET OR F.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ NO ❑ odlfificc 277a-. DATE OF DEATH (W... Day. Yr/ 28a. DATE SIGNED /Mo.. Day Yr.) 28b. TIME OF DEATH M 27b. DATE SIGNED Day. Yr/ 27t. TIME OF DEATH 28c. PRONOUNCED DEAD IMO.. Day, Yr.; 2tid. PRONOUNCED DEAD /HOUfI $ < 9 V(W... M in uai i� M _ ° 27d. To the best of my knowledge. death occurred al tit Buie, date and dace and due to the 28e. On the basis of examination ardlor investigation, in my opinion death occurred at ° < ° a '`[�auselsI stated. ( //) /� � J� (5 nature and Title l/� 1 the time, date and place and due to M ls) e cause stated. [Signature and Title 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BE CONSIDERED? 30.b WAS CONSENT GRANTED? %r ❑ YES ❑ NO UNKNOWN ❑ YES r' O ��---- ❑ YES NO 31_MWE ANQADDR,LyS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) � � . % � Y. Kr Vvt ►-se '7 N �- 32a. REGISTRAR t FILED BY REGISTRAR (MO. Day. Yr.) t'! NOV 2 21999