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<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 />DATE OF ISSUANCE
<br />7/5/2017
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Michael Lynn Brundage
<br />4: CITY;ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Dodge City, Kansas
<br />7. SOCIAL SECURITY NUMBER
<br />511.
<br />8b. FACILITY- NAME (If not Institution, give street and number)
<br />536 East 12th Street
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />2d. INJURY AT;WORK?
<br />❑YES ❑NO
<br />9d. STREET AND NUMBER
<br />536 East 12th Street
<br />Oa. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ® Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />George Cathel Brundage
<br />3. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or unit.) Yes ;Dates Unknown
<br />5. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation Not Embalmed
<br />® Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State(
<br />Kremer Funeral Home, Inc.. 6302 Maple Street. Omaha. Nebraska
<br />a. PART I. Enter the': Chain of eyeiits -- 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. Eater only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Myocardial Infarction
<br />disease or condition resulting
<br />In death! - DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially het conditions, if b) Hypertension
<br />any leadingte the cause hated
<br />on line a. - -
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c )
<br />(disease or injury that inaiated
<br />the events resuhibilin death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18. PART 11. 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 ptegnantwlthin past year
<br />❑ Pregnant at time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, tad pregnant 43 days to 1 year before death
<br />❑ Unknown if p regnant withinthe past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />23b. DATE SIGN
<br />8a. REGISTRAR'S SIGNATURE
<br />ED (Mo., Day, Yr.)
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />9b. COUNTY
<br />Hall
<br />16a. EMBALMER - SIGNATURE
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23c. TIME OF DEATH
<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 />201705654
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />65
<br />8a. PLACE OF DEATH
<br />' 3SPi'I ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name,
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Eva Blanche Faulds
<br />14a. INFORMANT-NAME
<br />George Simon Brundage
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Douglas Trade Service & Crematory Omaha
<br />CAUSE OF DEATH (See instructions and examples)
<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 />5b. UNDER .1 YEAR
<br />MOS.
<br />c. CITY' OR TOWN
<br />Grand Island
<br />DAYS
<br />9e. APT. NO.
<br />•
<br />25. 015 TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE • • ATION BEEN CONSIDERED?
<br />❑ YES gl NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 7 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Joseph E. Dobesh, Deputy County Attorney, 231 S Locust St, Gra • Island, Nebraska, 68802
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />2. SEX
<br />Male
<br />166. LICENSE NO.
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />OTHER ❑ Nursing Home /LTC
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9f. ZIP CODE
<br />68801
<br />21b. IF TRANSPORTATION INJURY
<br />Ei Driver /Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />STATE
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />Found May 9, 2017
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />April 3. 1952
<br />onset t
<br />L
<br />June 19, 2017 Unknown
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUt
<br />May 9, 2017 08:20 PM
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DEC €DENT..
<br />Son
<br />16c. DATE (Mo., Days Yr.)
<br />May 16, 2017
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68104
<br />death
<br />APPROXIMATE INTERVAL
<br />onset e 4000
<br />Hours
<br />onset to death
<br />Years
<br />onset to death
<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 AVAIIABI,
<br />TO COMPLETE CAUSE OF DEATH ?;,
<br />E] YES 0 N
<br />ZIP CODE"
<br />D DEAD
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Joseph E. Dobesh, Deputy County Attorney
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES 0
<br />DATE FILED BY REGISTRAR (M Day, Yr.)
<br />June 23, 2017
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