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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ronald Gene Brabander 2. SEX., ' Male 3. DATEOF'DEATH (Mo., Day, Yr.) Augltst'12, 2014 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 70 6b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DAIE OF BIRTH (Mo., Day, Yr.) .' February 13, 1944 MOS. DAYS HOURS., MINS. 7. SOCIAL SECURITY NUMBER 508 -52 -0109 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility IE ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4015 Anne Marie Ave. 19e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 1013. NAME OF SPOUSE (First, Middle, Last Suffix) If wife, give maiden name Margeret Ann Fruit 11. FATHER'S -NAME (First, Middle, Last, Suffix) Lyle Eugene Brabander 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Anita Mae Matthiesen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 1962 -1966 14a. INFORMANT -NAME Margeret Ann Brabander 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) August 14, 2014 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER I 18. 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, APPROXIMATE INTERVAL onset to death Minutes respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cardiopulmonary Arrest disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Sequentially list conditions, if b) Cardiac Event, NOS 1 Minutes any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Enter the UNDERLYING CAUSE c ) I (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ( onset to death LAST d) 1 I I 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: 0 Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 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) 22d. INJURY AT WORK? OYES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE ' E' w 8 F 0 z 23a. DATE OF DEATH (Mo., Day, Yr.) a s z i E g Y E a< z r O , o u O . O 8 ii ° t 24a. DATE SIGNED (Mo., Day, Yr.) August 14, 2014 24b. TIME OF DEATH Approx. 08:00 AM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) August 12, 2014 24d. TIME PRONOUNCED DEAD 08:43 AM u 3d. To the due to thof e my knowledge, death occurred at the time, date and place g 0 a n d due to the causes) stated. ( Si g nature and Title) z 24e. On IM basis of examination and/or investigation, in my opinion death occurred a! the time, date and place and due to the causes) sta ted. (Signature and TRIe) Nancy Berger- Schneider, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES SSUE r • ATION BEEN CONSIDERED? ID NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Nancy Berger- Schneider, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 1 28a. REGISTRAR'S SIGNATURE /1r / A - /�� _ ( 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 14, 2014 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AT HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA D flARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT41.43EC DATE OF ISSUANCE 08/19/2014 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN CERTIFICATE OF DEATH 201704430 S�7F17VLE $ CGDP R S./ST4NT STATE REGISTRAR PARTMEN7' OF HEALTH' AND OMAN SERVICES S RVICES 14 04042