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<br /> STATE OF NIBRASKA
<br /> 2#1601)VO$
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA tikOAXTMENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR-VIT,AL gBCORDS. ..
<br /> , . •. ,
<br /> DATE OF ISSIIINCE ....
<br /> $f 20.1605507
<br /> STANLEY S-COOPER
<br /> 10/16/2615
<br /> ASSISTANT,STATE REGISTPAR
<br /> DEPARTMENT OF HEALTH AND
<br /> LINCOLN, NEBRASKA HUMAN SERVICES
<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMANASERVICES .., 15 05915
<br /> CERTIFICATE OF DEATH ,
<br /> 1.DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.SEX '' 3.DATE OF DEATH(Mo.,Day,Yr.)
<br /> Lee Allen Bruhn Male October 9,2015
<br /> 4.CITY AND STATE OR TERRITORY,OR FOREIGN COUNTRY OF BIRTH 5a.AGE-Last Birthday 5b.UNDER 1 YEAR 5c.UNDER 1 DAY 6.DATE OF BIRTH(Mo.,Day,Yr.)
<br /> (Yrs.). MOS. DAYS HOURS MINS.
<br /> Grand Island, Nebraska 76 September 25, 1.939
<br /> 7.SOCIAL SECURITY NUMBER 8a.PLACE OF DEATH
<br /> 508-52-1312 HOSPITAL M Inpatient OTHER D Nursing Home/LTC 0 Hospice Facility
<br /> 8b.FACILITY-NAME(If not Institution,give street and number) 0 ER/Outpatient 0 Decedent's Home
<br /> CL
<br /> 0
<br /> 1.- CHI Health St.Francis 0 DOA 0 Other(Specify)
<br /> C.)
<br /> 1,11.1 8c.CITY OR TOWN OF DEATH(include Zip Code) 8d.COUNTY OF DEATH
<br /> L a Grand Island 68803 Hall
<br /> _I , 1
<br /> 9a.RESIDENCE-STATE 9b.COUNTY 9c.CITY OR TOWN
<br /> w Nebraska Hall Wood River
<br /> z
<br /> m 9d.STREET AND NUMBER 9e.APT.NO. 9f.ZIP CODE 9g.INSIDE CITY LIMITS
<br /> •
<br /> >,. 7• 1 952 West Burmood Road _ 68883 DYES 0 NO
<br /> sz,
<br /> 13 10a.MARITAL STATUS AT TIME OF DEATH gl Married 0 Never Married 10b.NAME OF SPOUSE(First, Middle, Last, Suffix)If wife,give maiden name
<br /> IE 0 Married,but separated 0 Widowed 0 Divorced 0 Unknown Joleen O'Brien
<br /> CD
<br /> I ,,...?.. 11.FATHER'S-NAME (First, Middle, Last, Suffix) 12.MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> Homer H Bruhn Mae E Reimers
<br /> CD Z I
<br /> 71.
<br />' E 13.EVER IN U.S.ARMED FORCES? Give dates of service if Yes. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT
<br /> 8 (Yes,No,or Unk.)No Joleen Bruhn Spouse
<br /> 12 15.METHOD OF DISPOSITION 16a.EMBALMER-SIGNATURE 16b.LICENSE NO. 16c.DATE(Mo.,Day,Yr.)
<br /> 2 El Burial 0 Donation Tracey Dietz 1328 October 14,2015
<br /> 0 Cremation 0 Entombment
<br /> 16d.CEMETERY,CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br /> 0 Removal 0 Other(Specify)
<br /> St. Mary's Cemetery Wood River Nebraska
<br /> 17a.FUNERAL HOME NAME AND MAILING ADDRESS(Street,City or Town,State) 17b.Zip Code
<br /> Apfel Funeral Home, 1123 W.2nd,Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH(See instructions and examples)
<br /> 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, APPROXIMATE INTERVAL
<br /> respiratory arrest,or ventricular fibrillation without showing the etiology.DO NOT ABBREVIATE.Enter only one cause on a line.Add additional lines if necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE(Final a)Respiratory Failure 10 Days
<br /> disease or condition resulting
<br /> in death)
<br /> DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions,it b)Pneumonia/sepsis - 10 Days
<br /> any,leading to the cause listed
<br /> an line a. )
<br /> DUE TO,OR AS A CONSEQUENCE OF: onset to death i
<br /> Enter the UNDERLYING CAUSE c)
<br /> (disease or injury that initiated
<br /> the events resulting in death) DUE TO,OR AS A CONSEQUENCE OF: t onset to death
<br /> LAST d)
<br /> t
<br /> 18.PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19.WAS MEDICAL EXAMINER
<br /> Diabetes Mellitus,obesity OR CORONER CONTACTED?
<br /> DYES Dil NO
<br /> CC
<br /> GU
<br /> 20.IF FEMALE: '21a.MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c.WAS AN AUTOPSY PERFORMED?
<br /> I- 0 Not pregnant within past year bil Natural El Homicide 0 Driver/Operator
<br /> CC 0 YES IXI NO ar
<br /> w 0 Pregnant at time of death 0 Passenger
<br /> Accident D Pending Investigation
<br /> •• 0 Not pregnant,but pregnant within 42 days of death 21d.WERE AUTOPSY FINDINGS AVAILABLE
<br /> 0 Suicide 0 Could not be determined 0 Pedestrian ned Other(Specify) TO COMPLETE CAUSE OF DEATH?
<br /> t0 Not pregnant,but pregnant 43 days to 1 year before death 0
<br /> 0 Unknown If pregnant within the past year 0 YES 0 NO
<br /> CL
<br /> E 22a.DATE OF INJURY(Mo.,Day,Yr.) 22b.TIME OF INJURY 22c.PLACE OF INJURY-At home,farm,street,factory,office building,construction site,etc.(Specify)
<br /> o
<br /> (..)
<br /> 0
<br /> .0 22d.INJURY AT WORK? 22e.DESCRIBE HOW INJURY OCCURRED
<br /> 0
<br /> i-
<br /> DYES ONO
<br /> 22f.LOCATION OF INJURY-STREET&NUMBER,APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 23a.DATE OF DEATH(Mo.,Day,Yr.) 24a.DATE SIGNED(Mo.,Day,Yr.) 24b.TIME OF DEATH
<br /> PI October 9,2015
<br /> 1 14- 23b.DATE SIGNED(Mo.,Day,Yr.) 23c.TIME OF DEATH I E ). 24c.PRONOUNCED DEAD(Mo.,Day,Yr.)24d.TIME PRONOUNCED DEAD
<br /> October 12,2015
<br /> 1 s‘-', ' 10:50 PM A a.vt.J
<br /> I 12 8 i
<br /> .6 2 3d.To the best of my knowledge death occurred at the time,date and(Nave ''' -2 24e.On the basis of examination and/or investIgation,In my opinion death occurred at
<br /> due to the cause(s)stated.(Signature and Title) '
<br /> g i
<br /> i
<br /> !g 8
<br /> the time,data and place and due to the cause(s)stated.(Signature and Title)
<br /> Ryan D.Crouch, DO
<br /> 25.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b.WAS CONSENT GRANTED?
<br /> 0 YES EI NO 0 PROBABLY 0 UNKNOWN 0 YES Ej NO Not Applicable if 26a is NO 0 YES 0 NO
<br /> 27.NAME,TITLE AND ADDRESS OF CERTIFIER(Type or Print)
<br /> Ryan D.Crouch,DO,800 N Alpha Street,Grand Island, Nebraska,68803
<br /> 28a.REGISTRAR'S SIGNATURE A 28b.DATE FILED BY REGISTRAR(Mo.,Day,Yr.)
<br /> ...
<br /> October 13,2015
<br /> I.
<br /> Attitwai
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