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<br />STATE OF NEBRASKA
<br />lliiiiimwskteri-,
<br />WHEN THIS ! ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />201703340
<br />7/1/2016 201604469
<br />LINCOLN, NEBRASKA
<br />DATE OF ISSUANCE
<br />siattimmie
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Ann Eileen Bruns
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Spalding, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505 -02 -1446
<br />86. FACILITY - NAME (If not Institution, give street and number)
<br />PC
<br />0
<br />131.1 N St
<br />1 0 '2 18c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />o Grand Island 68801
<br />9a RESIDENCE.STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9d. STREET AND `NUMBER
<br />1311 N. Geddes St.
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Niarrted, butseparated ❑ Widowed ❑ Divorced ❑ Unknown
<br />E 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />0 (yes, No, or Unk.) No
<br />15. METHOD OF diSPOSITIQN
<br />10- ❑ Burial "❑ Donation
<br />® Cremation ❑ Entombment
<br />Removal ❑ Other (Specify)
<br />5a. AGE Last Birthday
<br />(Yrs
<br />54
<br />5b, UNDER YEAR
<br />MOS,
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />ERIOUtpatient
<br />0 DOA
<br />16a. EMBALMER- SIGNATURE
<br />Not Embalmed
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />9e. APT. NO.
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />OTHER ❑ Nursing Home /LTC
<br />® Decedent's Home
<br />❑ Other(Specify)
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 16, 2016
<br />9f. ZIP CODE
<br />68801
<br />6. DATE OF BIRTH (Ma., Day, Yr.)
<br />February 14, 1962
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />94 CITY OR TOWN
<br />Grand Island !'
<br />9g. INSIDE CITY a Mi is
<br />® YES ❑ NO
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Dennis Wayne Bruns
<br />1. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert William Moore
<br />I ; 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Elizabeth Josephine Clark
<br />14a. INFORMANT -NAME
<br />Dennis Wayne Bruns
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (Mo., Day Yr.)
<br />June 18, 2016
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17b, Sip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />4a. PART 1. Enter the chain of events- - diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one CSUSe on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Metastatic Sarcoma, Of Left Thigh
<br />disease or condition resulting
<br />APPROXIMATE INTERVAL
<br />onset to death'
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list COndltions. +f b)
<br />any, feeding to the cause hated;
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />disease Of injury that initiated.:
<br />t he events reaeh1ng in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF FEMALE; '•
<br />Not pregnant, within peat year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not preOnant, bid ptgnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />2 2d. INJURY AT WOR)( ?:
<br />❑ YES ©NO
<br />22f. LOCATION OF INJURY- STREET & NUMBER, APT.NO.
<br />c)
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />I 22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23a. DATE OF (Mo., Day, Yr.)
<br />•June 1.6, 2016
<br />234'. DATE S1fsNED Day, Yr.) 23c. TIME OF DEATH
<br />Lune
<br />29;2013 02:19 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Travis S. Hageman, MD
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Specify)
<br />CITY/TOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED
<br />❑ YES ®NO
<br />25. Dif) TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S. Harman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a.<: REGISTRAR'S SIGNATURE
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Drives /operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑
<br />Other (Specify)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />A. Ca 4%4
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />onset to death,;.
<br />onset to death
<br />16 03659
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. 011 me oasis of cxa ^' ^ation n'd'er investigation, in my opinion death occurred at
<br />time, date and place and due to the cause(s) stated. (Signar;.re and "fide)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO I . YES
<br />28b. DATE FILED BY REGISTRAR (Ma., Day, Y<
<br />June 29, 2016
<br />
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