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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 OF1SSUANCE
<br />4/12/2019
<br />LINCOLN, NEBRASKA
<br />mummer
<br />„go 6.--
<br />©
<br />ASSISTANT STATE REGISTRAR
<br />RUSSELL FOSI,ER
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix).
<br />Earl Thomas Brodman
<br />2. SEX
<br />•
<br />Male
<br />4. CITY-AN3? STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />CD
<br />.
<br />Woodson County, Kansas
<br />7.. SQCIALSECURITY NUMBER
<br />513:20-0560
<br />5e, AGE. • Last Birthday 8b. UNDE
<br />(Yn.)
<br />94
<br />MOS.
<br />1 YEAR Sc. UNDER 1 DAY
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 2, 2019
<br />8. DATEOF BIRTHIMO., 'Day,Yr4
<br />November 27, 1924
<br />,tom, 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Ts Grand Island 68803
<br />9a RESIDENCE -STATE
<br />11 Nebraska
<br />Sb. FACILITY.NAME (If not Institution, give street and number)
<br />Tiffany Sguare Care Center .
<br />9d. STREET AND NUMBER
<br />1817 Stagecoach Rd
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />OTHER ® Nursing Home/LTC ❑ Hospice Facility
<br />0 Decedent's Home
<br />[� Other (Specify)
<br />c
<br />7
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Manied
<br />❑ Married, butseparated s 0 Widowed ❑ Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Thomas Brodman
<br />Z' 13, EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />(Yea. No, or Unk.) Yes 08/26/1943-10/22/1945
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<br />d
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<br />15. METHOD OF E ISPOS(TION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand (stand
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITYLIM1TS''
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Shirley Ann Gasda.
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Emma Bulk
<br />14a. INFORMANT -NAME:
<br />Shirley Ann Brodman
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<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 />18b. LICENSE NO.
<br />1454
<br />CITY /TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />16c. DATE (Mo., Day, Yr.)
<br />April 6, 2019
<br />STATE
<br />Nebraska
<br />17b, 2:lpCode
<br />68801
<br />le, PART 1. Etter theamid of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter tannin* events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Chronic Congestive Heart Failure
<br />disease or condition resulting
<br />(n death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially listcondktona, if i; b)
<br />any, Brading to the cause tatted
<br />on linea....
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />Idiseeee or injury t int initiated
<br />the avems reswting in deeth) DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL.
<br />onset to death
<br />10 Years
<br />onset to death
<br />onset to death'<
<br />18. PART I). OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />m
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<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />❑ - Presnant et time of death
<br />0 Not pregnant; but pregnant within a2 days of death
<br />❑ Net pregnant, put pregnant 43 days to 1 year before death
<br />0 Unknawn if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Gould not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 DriverlOperator
<br />❑ Passenger
<br />0 Pedestrian
<br />Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES El NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY PNDINps AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />to
<br />22d. INJURY AT WORK?
<br />❑YE$ 0 N
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 2. 201 9'
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH
<br />April 2, 201A 02:32 AM
<br />3d. To the best of my kncwledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />icliard Fruehlinq, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED 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 causal.) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSUE: DONATION BEEN CONSIDERED?
<br />0 YES E NO 0 PROBABLY 0 UNKNOWN 0 YES NO
<br />27. NAME, T.TLE AND ADDRESS OF CERTIFIER (Type or Pr)nt)
<br />Richard Friiehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, :Nabraska, 68803
<br />REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED? s
<br />Not Applicable If 28a is NO 0 YES ❑ NO
<br />28a.
<br />28b. DATE FILED BY REGISTRAR (510 Day, Yr.)
<br />April 8, 2019
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