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STATE OF NEBRASKA WHEN THIS '<" 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 8/25/2016 LINCOLN NEBRASKA 20170013g STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Coe STANLEY S.' COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES Q w re 2 u. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) James Lawrence Runge 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Monroe, Ne braska 7. SOCIAL SECURITY NUMBER 506 -46 -2247 8b. FACILITY -NAME (0 not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 318 White Ave 10a_ MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Emil Runge 13. EVER IN U.S, ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation E Cremation ❑ Entombment ❑ Renoval ❑ Other(Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)'; Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska IMMEDIATE CAUSE (Final disease or condition resuking in death) Segdentially list COndltion4, any, 1554, g tpthe cause gated. on linea. Enter the UNDERLYING CAUSE {disease dr Injury that ini11ate1:,, the events resutting:,h death) LAST 22d. INJURY ADW.RI( ❑YES ❑NO 2 8 a - R EG I S T RAR 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Matthew T. Myers 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Memorial Park Crematory DUE TO, OR AS A CONSEQUENCE OF: 1llnterstitial Lung Disease DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 20.IFFEMALE: ❑ Not pregnantwkhin past year ❑ Pregnant at time of death Not pregnant, but pregnant within 42 days of death © Nbt prepnam, pregnant .44 4 ys to 1 year before death ❑ Uniknown rf pregnant within the past year. 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 5. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 5a. AGE Last Birthday (Yrs ) 76 NATURE � - 5b. UNDER 1 YEAR MOS 8a. PLACE OF DEATH HOSPITAL E Inpatient OTHER ❑ E F/Gutpatient ❑ DOA 9c, CITY OR TOWN. Grand Island' 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined o LL E t U Z DATE OF DEATH (Mo., Day, Yr.) August 6, 2016 23c. TIME OF DEATH 09:40 AM 236. DATE SIGNED (Mo., Day, Yr.) August 9, 2016 u 4 0 3d. To the best of my knowledge, death occurred at the time, date and place 13 o and due to the cause(s) stated. (Signature and Title) r g9 Douglas Herbek, MD ❑ passenger ❑ pedestrian 0 Other,(.Specify) 26a. HAS ORGAN OR TISSUE DONATION BEEN' CONSIDERED? ❑ YES 2 NO DAYS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8d. COUNTY OF DEATH Hall 12. MOTHER'S -NAME (First, Middle, Lela Walker CITY / TOWN Grand Island CAUSE OF DEATH (See instructions and examples) 13. PART L Enter the s of events -- diseases, injuries, or complications-that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, respiratory arreat, or Ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Acute Respiratory Failure 24a. DATE, SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68803 10b. NAME OF SPOUSE (First, .:Middle, Last, Suffix) If wife, give maiden name Wanda Kutschkau 14a. INFORMANT - NAME. -.. Wanda Runge 16b. LICENSE NO. 1411 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 3. DATE OF DEATH (Mo., Day, Yr.) August 6, 2016 6. DATE OF BIRTH (Mo., Day + Yr.) August 12, 1939 Maiden Surname) ❑ Hospice Facility 9g. INSIDE CITY LIMITS' 2 YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) August 10, 2016 STATE .Nebraska 17b, ZIP�Code ;` 68803 APPROXIMATE)NTER onset to death 2 Months onset to;death onset to death onset to death? 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES- E NO 2i b, IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? ❑ Driver /Operator ❑ YES E N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCAT(ON OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and. Title). 26b. WAS CONSENT GRANTED? : Not Applicable if 26a is NO ❑ YES t. f 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Douglas Herbek,: 2444 W. Faidley Avenue, Grand Island, Nebraska, 803 28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.) August 19, 2016 (A3 CO (D