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' /i:. t r ',ri .1 nri 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 7/1/2016 LINCOLN NEBRASKA 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 60. FACILITY -NAME (If not IpStitution, give street and number) 1311 N. Geddes St. 8c. CITY OR TOWN OF DEPTH (Include Zip Code) Grand Island 68801 9a; RESiDENCE- STATE. 1t Spalding, Nebraska. Nebraska 25. DID TOBACCO U 9d. STREET AND NUMBER 1311 N. Geddes St. [Oa. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated f ❑ Widowed ❑ Divorced ❑ Unknown IMMEDIATE CAUSE (Final disease or condition resulting g deaths Sequ#Rtiany list cbrltltiotts, it j b) any, leading tD the Gaese listed is Enter the UNDERLYING CAUSE ;(disease or injury _that initiated Bic events redultijg m death) LAST: . 22d. INJURY AT WORK? ❑YES 0 N 23a. DATE OF DEATH (Mo., Day, Yr.) 28a. REGISTRAR'S SIGNATURE STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 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 15. METHOD OF DISPOSITION ❑ Burial © Donation ® Cremation ❑ Entombment Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 0. IF FEMALE; Not pregnant Within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnadt days to 1 year before death Unknatvn if pregnant wdftiinthe past year 9b. COUNTY Hall 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 1 22e. DESCRIBE HOW INJURY OCCURRED 1 14a. INFORM ANT - NAME Dennis Wayne Bruns 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN June 46; 2016 b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH June 29, 2016 02:19 AM 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 20170074 5a. AGE - Last Birthday (YrS.) 54 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient 0 ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name_. Dennis Wayne Bruns 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island. Nebraska a) Metastatic Sarcoma, Of Left Thigh 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined a 5b. UNDER 1 YEAR MOS. 2. MOTHER'S -NAME (First, Middle, Maiden Surname) Elizabeth Josephine Clark CAUSE OF DEATH (See instructions and examples) Aft7I. Enter the amine events- - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, iratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line, Add additional lines if necessary. IMMEDIATE CAUSE: DAYS 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) I a z O C ;a U 26a. HAS ORGAN OR T I ISSUE DON ATION BEEN CONSIDERED? CO NTRIBUTE TO THE DEATH? © Y S ad NO - ° ❑ PROBABLY ❑ UNKNOWN ❑ YES EI NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Travis S.Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS 8d. COUNTY OF DEATH Hall b. LICENSE NO. CITY I TOWN Gibbon 9f. ZIP CODE 68801 lb, IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other )Specify) 24a. DATE SIGNED (Mo., Day, Yr.) MINS. OTHER ❑ Nursing Home /LTC Decedent's Home ❑ Other (Specify) PRONOUNCED DEAD (Mo., Day, Yr.) onset to. 3. DATE OF DEATH (Mo., Day, Yr ) June 16, 2016 6. DATE OF BIRTH (Mo., Day, Yr.). February 14, 1962 ❑ Hospice Facility 9g. INSIDE CITY LIMiTS • ad YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Husband 16c. DATE (Mo., pay, ; Yr.) June 18, 2016 17b, Z)pi 68801 APPROXIMATE onset to death Years onset to., death . onset to death STATE Nebraska 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES ®NO 21c. WAS AN AUTOPSY PERFORMED/ ❑ YES ad NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE Q.F DEATH? ❑YES NO STATE ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAR 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 28b. DATE FILED BY REGISTRAR 1M Day June 29, 2016 INTERVAL.