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<br />STATE OF NEBRASKA "`
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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,
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />4/17/2017
<br />LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />202100174
<br />VITAL
<br />STANLEY S. DOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1. DECEDENTS -NAME (First; Middle, Last, Suffix)
<br />Larry Bennett Runge
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />March 30, 2017
<br />4. CITY AND STATEORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE Last Birthday
<br />(Yrs,)
<br />68
<br />,5b UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />April 29, 1948
<br />7. SOCIAL SECURITY NUMBER
<br />506-58-9342
<br />8b. FACILITY -NAME (If not Imititutlon, give street and number)
<br />1-r •CHI Health St. Francis
<br />Itei 8c. CITY OR TOWN'OF DEATH (include Zip Code)
<br />c Grand. Island 68803
<br />9a:.: RESCOENC E -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />11 Via Como
<br />Bb. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC
<br />ER/Outpatient 0 Decedent's Home
<br />❑ DOA fl Otte: (Specify? _
<br />ilia. MARITAL STATUS AT TIME OF DEATH gl Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced ❑ Unknown
<br />41. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Dale Runge
<br />13. EVER IN US, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />18. METHOD OF DISPOSITION
<br />I Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal <❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY Llf&ITS'
<br />® YES ❑ NO
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name ;
<br />Linda Diane Bauld
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Leila Douglass
<br />14a. INFORMANT -NAME
<br />Linda Diane Runge
<br />18a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />18b. LICENSE NO.
<br />1454
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16e. DATE (Mo., Day, Yr.)
<br />April 3, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery
<br />'17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b. Zip Code'.
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />tit. PART I. Enter Mechlin of events- diseases, injuries, or compllcauons-that directly caused the death. DO NOT enterUpminel events such as cardiac arrest,
<br />respiratory xrrest, or ventricular flbriilatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one reuse en a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEIMATE CAUSE (Final a)Fulminant Liver Failure
<br />disease or condition resulting
<br />in death)
<br />Sequentially lilt caktltla le if
<br />any, lading ttl the tees, listed
<br />on linear::: _.._ _._..
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Multiorganism Sepsis (E. Coli Sepsis/UTI, VRE Sepsis And M
<br />Aeurginosa UTI/Sepsis)
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C) Pancytopenia Due To Chemotherapy/Radiation Therapy
<br />Iclseawe at injury 11+11 initiated
<br />tit, events resulting in death)
<br />LAST..
<br />u
<br />Iti drug Resistant Pseudomont
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)NHL (Follicular Large Cell Non -cleaved With Conversion To Diffuse Large B Cell)
<br />onset to death
<br />2 Weeks
<br />onset to death
<br />Weeks
<br />onset to deeds
<br />Years
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Neurogenic Bladder, Back Pain With Neuropathic Leg Pain With LE Parasthesia, H//0 Mesenteric Thrombosis On Chronic
<br />Couitladin, Perirectal Ulceration Due To Chemo/radiation and Moisture Associated Derma Ms Due To Stool, Thrush
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />UI
<br />2o. IF FEMALE:
<br />0 Not pregnant within gnat year
<br />❑ Pregnant at time of death
<br />❑ Not pmgnenk but pregnant within 42 days of death
<br />❑ No; pregnant;:but pregnant a days to I year before death
<br />❑ Unknown it pregnant wlthuil tris past year
<br />E22a. DATE OF INJURY (Mo., Day, Yr.)
<br />8
<br />221. INJURY•ATWORK7
<br />❑YES ❑ NO
<br />21a. MANNER OF DEATH
<br />Natural ❑ Noontide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />21b< IF TRANSPORTATION INJURY
<br />© briverlOperator
<br />0 Passenger
<br />0 Pedestrian
<br />Otter iaPecxlr)
<br />21c. WAS AN AUTOPSY! PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE,
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑NO
<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 />ver. CATs L•2-. TH (6i.:., Day, Yr.)
<br />CITYITOWN
<br />>1iuk March 30, 2017
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />April 1. 2017 03:08 PM
<br />w
<br />Ci
<br />tad. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and mho
<br />Kimberly A. Nickels, MD
<br />STATE 21P CODE
<br />.40. DA 3N_i3,1.c , Say, Y4, i 24:. TM! ;F CEI:11:
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.1 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 cause(s) stated. (Signature and Tide)
<br />26a. HAS ORGAN OR TISSUE r • ATiON 8EENCONSIDERED?
<br />❑ YES 6'a
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES bil NO ❑ PROBABLY 0 UNKNOWN
<br />27. NAME TILE ". 'D ACCRE^PS OF CERTIFIER (Type or Print
<br />Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR
<br />SIGNATURE JI6-
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO [) Yes Q NO
<br />28b. DATE FILED BY REGISTRAR1Mo,Day, Yr.)
<br />April 12, 2017
<br />
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