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Y" � d4ellatikhoi Y,,■,refiareeiLl �rl.d
<br />a aaNte � x .......
<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 RECO
<br />DATE OF ISSUANCE
<br />JUL 16 2018
<br />LINCOLN, NEBRASKA
<br />(� Q Q RUSSELL FOSLER
<br />2 0 1 8 0 4 C7 2 7 INTEg23i DEPARTMENT SOTAFTERDREGISTRAR
<br />ALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPo
<br />CERTIFICATE OF DEATH
<br />I. DECEDENT'S -NAME (First,
<br />David
<br />4 , CITY AND STATE ORTERRtTORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ord, Nebraska
<br />7 SOCIAL SECURITY NUMBER
<br />5(15,-06-1117
<br />66, FACILITY -NA
<br />103 Solar St.
<br />Bc, CIFYIORTbWN OF. DEATH (Include Zip Code)
<br />Aida 68810
<br />a RESIOENCE•STATE
<br />Nebraska
<br />9d. STREETAND NUMBER
<br />10.3 Solar St.
<br />19a. MARITAL STATUS AT TIME OF DEATIA Married ❑ Never Married
<br />❑ Married. but separaled 0 Widowed 0 Divorced 0 Unknown
<br />13. Et/ERIN U S.ARMED FORCES? Give dales a1 service it yes.
<br />(Yes, no. or unk -) no
<br />15. METHOD OF DISPOSITION
<br />Burial 0!:Donation
<br />UEtemat(On 0:Ehtombment
<br />3 Removal Q O!her(Specify)
<br />iME{SSkfiECkSISE
<br />diseaseoe conddldnaeaulin
<br />In death)
<br />(II not inslilution, give street and number)
<br />E (FUSt,
<br />Albin
<br />Sequentially 11stconditions, if
<br />any, kadldB td I1iteause limed
<br />en Iiny:#,
<br />Enter g e . 11.10 .OrtI P\UBE
<br />(dleetreopr In)teythatInitiated
<br />the events resultingin death)
<br />LAST
<br />'4k the (reslat m
<br />6,06e lags
<br />OF Wit/ AY (MO, Day, Yt )
<br />224 INJURY AT WORN ?.
<br />Q YES 0NO
<br />(a)
<br />ED ( ., Day. Yr) ..
<br />41
<br />Middle, Last,
<br />Alan Bruha
<br />Middle,
<br />96. COUNTY
<br />Hall
<br />16a. EME ER-SIGNATURE
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />DUE. TO. OR AS A CONSEQUENCE OF.
<br />20. IF FEMALE:
<br />E} Notpregnallt within past year
<br />.I PregnanlglhnreotdeaU
<br />No pregnant, burpregnant within 42 days of death
<br />0 Not pteQnanI but pregnant 43 disg lot yCar beFore death
<br />Ia Unk11own d pteglaent within the pool year
<br />226. TIME OF INJURY
<br />m
<br />R2e,DESCRIBE HOW INJURY OCCURRED
<br />OF INJURY - STREET 6 NUMBER. APT.` NO
<br />dge. de
<br />Sta
<br />Last, .:S:dllia)
<br />Bruha
<br />5a. AGE-Last Bitthday
<br />Yrs.)
<br />44
<br />23a.0ATE OF DEATH (Mu:, Day. Yr).
<br />C'
<br />8a, PLACE OF DEATH
<br />LIOSPITAU
<br />Suffix)
<br />59. UNDER 1YEAR7
<br />Sc. UNDER t DAY
<br />MOS.
<br />DAYS
<br />9c. CITY OR TOWN
<br />Alda
<br />12: MOTHER'S -NAME {First,
<br />Alice
<br />12. SEX
<br />Male
<br />HOURS
<br />MIns.
<br />Ed. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO
<br />97 ZIP CODE
<br />68810
<br />lob NAME OF SPOUSE (First, Mrddle&Last, Suliiej',11 wife, give maiden acme
<br />Janet Powers- Lybarger
<br />t da. INFORMANT -NAME
<br />Janet Bruha
<br />red. CEMETERY. CREMATORY DR HER LOCATION
<br />Ord Bohemian Cemetery Ord, NE
<br />16b. LICENSE NO.
<br />1198
<br />CAUSE OF DEATH {See instructions and Boa
<br />CITYI TOWN
<br />t7a FUNERAL HOME NAME AND MAIL NG ADDRESS )Street, City or Town. Stale)
<br />Ord McMOrial Chapel, Inc. NW HWY 11, P ,O. Box 230 Ord., NE
<br />triples)
<br />18. PART I. Enter Me chain of everts -- diseases, injuries, or complications -- that Erecilycadseil the death. DO NOT enter terollnatevents such as cardiac arrest,
<br />respiratory arrest. or ventricular tibrination without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add addillonal does if necessary,
<br />IMMEDIATE CAUSE:
<br />3. DATE OF DEATH (Ma.. Day, Yr.)
<br />June 2, 2007
<br />6. DATE OF BIRTH (MO., Day, Yr.)
<br />December 27, 1962
<br />OTHER O Nursing Homer.TC Q Hospice Facility
<br />XI Decedent's Home
<br />❑ Other (Specify)
<br />17b. Zip Code
<br />I
<br />onset to death
<br />9g. INSIDE CITY LIMITS
<br />}Sx YES 0 NO
<br />Middle. Maiden Surname)
<br />Kirby
<br />14b. RELATIONSHIP TO DECEDENT
<br />spouse
<br />16c. DATE (Mo.. Day. Yr.)
<br />June 6,`2007
<br />STATE
<br />1 68862
<br />APPROXIMATE INTERVAL
<br />DUE TO, OR AS ACONSEOUENCE OF
<br />I onset to death
<br />a. PART II.OTFIE18 SIGNIFICANT CONDITIONS-Condil la ns
<br />ontrrbuling to the death bat not (*sal
<br />21 a_MyNNER OF DEATH
<br />Natural 0 Homicide
<br />Q Accident❑ Pend616.lnvesAg9Ilon
<br />0 Suicide ❑ Could not be determined
<br />CITYtT
<br />23c TIME OF DEATH ,y
<br />* S 11
<br />r ed al me lime, dale and place
<br />re and Mllre1 V
<br />e.
<br />220. PLAGE OP INJURY.A
<br />lOm8,lar
<br />210.1F TRANSPORTATION INJURY
<br />CI Dd*Mroperarer
<br />Q Passenger
<br />PedeSlfieo
<br />O Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO -'
<br />COMPLETE CAUSE OF DEATH'?
<br />0 YES ONO
<br />'eel teCllry. office building, construction site. etc. (Specify)
<br />CONSIDERED?
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />I onset te�(eath
<br />19. WAS MEDICAL EXAMINER'!
<br />OR CORONER CONTACTED?
<br />Q YES
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />Q YES. ,49
<br />240. TIME OF DEATH
<br />241. T1MEPRONOIJNCEO DEAD
<br />a. On the treats of a ammenon andyor 6rve ligation, in my opinion deal, occurred at
<br />115 @time, date.Bddplace end due to the cause(s) staled. (Signature and Title)
<br />260. WAS CONSENT GRANTED?
<br />Not Applicable i1 26a Is NO 0 YE
<br />25. DID TOBACCO USE Ce TRIEUTETOTHE DEATH? � 26e. HAS ORGAN OR TISSUE DONATION BEET
<br />0 YES ❑ NO � PROBABLY //_ ([,,T�/J A 1 /,.. ,,I ��1(}��fT
<br />(i ftetd I ADDRESS
<br />"V f C 11 , / E�RiP' SIC{ CORONER'S P 0 YES
<br />116, ttYS � j. 9 (� UJN�T4fe (i,P 1I m{
<br />rtf.e YI S(ere1d. ME 40E8 1
<br />20a. REGISTRAR'S SIGNATURE M , f t l /cif ? 280. DATE FILED BY REGISTRAR (MO.. Dag YT.)
<br />JUN 11 2007
<br />
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