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'35_'ivt'avO. _.ia...viCMY.. airytN 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 RECORD 0 2 0 0 6 0 4 0 11%. dia4 DATE OF ISSUANCE 5/21/2020 LINCOLN, NEBRASKA SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND IIIWAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH t � S / 9�t �i��tlle 20 06344 Pursuant to section 302413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. i. DECEDENTS -NAME (First, Middle, Last, Suffix) Kathy Marie Brummund 2. SEX Female 3. DATE OF DEATH (MO., Day, Yr.) May 13, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 513. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Hastings, Nebraska (Yrs.) 70 MOS. DAYS HOURS MINS. December 27, 1949 7. SOCIAL SECURITY NUMBER 530-40-3797 8a. PLACE OF DEATH HOSPITAL E Inpatient OTHER ❑ Nursing Home/LTC 0 Hospipe Fap)tity 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis ❑ 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 Doniphan 9d. STREET AND:NUMBER. 106 W. Bartelt Avenue 9e. APT. NO. 9f. ZIP CODE 68832 90. INSIDE CITY L)MITS,, 2 YES; 0 NO 108. MARITAL STATLJ$ AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Larry Lee Brummund 11. FATHER'S -NAME {First, Middle, Last, Suffix) Clayton Mays 12. MOTHER'S -NAME (First, Middle, Maiden Surname) ;. Jean Daugherty 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Larry Lee Brummund 14b. RELATIONSHIP TODECEDENT Spouse 15. METHOD OF DISPOSITION ❑ iBurial ❑Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) May 15, 2020 ® Cremation 0 Entombment ❑Removal❑Other (Specify) 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) 18. PART I. Enter the chain of events- -diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL 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) Pneumonia disaase of tonditiofi resulting onset to death Days'. m death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions. if b)Acute Hypoxia any, leading to the cause listed tine a. onset to death Days on DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING cause c)Acute Kidney Failure (disea§C of injury that Irdttated onset to death Days the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART 11. OTHER SIGNW/CANT CONDITIONS-Condltions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 20. IF FEMALE: E Not pregnant within past year ❑Pregnant time f death St oeatPassenger P 21a. MANNER OF DEATH E Natural 0 Homicide ❑ Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E" NO ❑ Net pregnant,; but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year Suicide Coultl not be tleterminetl ❑ ❑ ❑ Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 228. DATE OF INJURY (Ma.„ 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? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY ` STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICALCERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) May 13, 2020 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) May 15, 2020 23c. TIME OF DEATH 05:15 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of My knowledge, death occurred at the time, date and place end due to the cause(S) stated. (Signature and Title) Richard Fruehiing, MD 24e. On the basis of examination and/or investigation, in my opinion death os;urredsat the time, date and place and due to the cause(s) stated. (Signature and TttIe) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES NI NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES E NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO - 0 YES 0 NO 27. NAME, TITLE<ANDADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 3 > ��( Z A %�4/1--/ , iyyL 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 18, 2020 It CD N