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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA I '-T,OF HEALTH,4ND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F4*'.C y
<br />DATE OF ISSUANCE
<br />06/19/2014 , ��" Y . AILE�r . Co
<br />202107-34'2..# F� S hNF�TaTE
<br />fir:
<br />LINCOLN, NEBRASKA �� , CENA
<br />STATE OF NEBRASKA •DEPARTMENT OF HEALTH AND HU S ° t/IC
<br />CERTIFICATE OF DEATH !.' '•.?r.,_ ' ,� ,:%: 1402981
<br />1. DECEDENTS -NAME (First, Middle, Last, SuRbt)'+ DTE (Mo, Day, Yr.)
<br />Audra Mae Brummund t'lre-. Jure 14
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />AGE - Last Birthday
<br />Pb. UNDER 1 YEAR Sc. R i SAY '6c D a."F BUITH (Mo., Day, Yr.)
<br />15a.
<br />(Yrs.)
<br />MOS. DAYS HOURS MINS.
<br />Hamilton County, Nebraska
<br />89
<br />I April 2, 1925
<br />7. SOCIAL SECURITY NUMBER
<br />Be. PLACE OF DEATH
<br />505-72-2503
<br />HOSP Inpatient OTHER ® Nursing HomdLTC ❑ Hospice Facility
<br />❑ ERIOutpatlent ❑ Decedent's Home
<br />8b. FACILITY -NAME (K not Institution, give street and number)
<br />!r
<br />Golden LMngCenter-Grand Island Lakeview
<br />❑ DOA ❑ other miew l
<br />f. CITY OR TOwN OF DEATH (Include Zip Code)
<br />ad. COUNTY OF DEATH
<br />o
<br />Grand Island 68801
<br />Hall
<br />I9a.
<br />RESIDENCE -STATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />z
<br />Nebraska
<br />Hail
<br />Doniphan
<br />LL
<br />9d. STREET AND NUMBER
<br />APT. NO.
<br />9f. ZIP CODE
<br />9g. INSIDE CITY LIMITS
<br />U.
<br />103 W 8th Rd
<br />68832 �.
<br />❑ YES ® No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Murled ❑ Newr Man•Nd
<br />10b. NAME OF SPOUSE (First, Middle, Last, 3ufBx) x wife, give molder name
<br />is
<br />❑Hurled, but separeted ❑ WMovred ❑ Dlvo►gd ❑unknown
<br />Robert Earl Brummund
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)12.
<br />MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Edward Bayne
<br />Edith Jensen
<br />a
<br />E
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service K Yes.
<br />I
<br />14a. INFORMANT -NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />3
<br />(Yes, No, or Unk.) No
<br />Robert Earl Brummund
<br />Husband
<br />15. METHOD OF DISPOSmON
<br />16a. EMBALMER -SIGNATURE
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />12
<br />❑ Burial ❑ Donation
<br />Not Embalmed
<br />June 16, 2014
<br />n ❑Entobment
<br />®m
<br />16d.
<br />16d CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />Rmoval
<br />❑ Removal ❑Other (Specify)
<br />Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Sheet, City or Town, Stab)
<br />17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />68801
<br />CAUSE OF DEATH (See Instructions and exam
<br />I& PART I. Einar cine eholn of events• abeaes. Mhnies, or cor plladons4hat directly caused tho dada. DO NOT enter bmdnel ovenb such a candbe onset, : APPROXIMATE INTERVAL
<br />raWrMM aweeL or vaMcndar fibrillation without showing on etiology. DO NOT ABBREVIATE. Enter only ono cause on a Aim. Add additional lines N necessary.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final a) Multi system Organ Failure : Days
<br />disease or condidon resulting
<br />In asam) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />saauenwly Nat condwom. N b) End Stage Dementia E Months
<br />any. lading to aro cause listed
<br />on INw a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE C)
<br />(dbease or M*q that hnNbtsd
<br />the ovanb readling In loth) DUE TO, OR AS A CONSEQUENCE OF: Onset to death
<br />LAST d)
<br />18. PART B. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In tM underlying couw given In PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />Ovarian Caner, Hypertension, Kidney Disease
<br />OR CORONER CONTACTED?
<br />I
<br />❑ YES ® NO
<br />cc
<br />W
<br />LL
<br />0. IF FEMALE:
<br />21a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ Not wogmnt ww do past you
<br />® Natural ❑ Horeiclds
<br />❑ mk-dOparatu
<br />❑YES ®NO
<br />Uj
<br />[]Peg nantat thin of doth
<br />❑ Accident ❑ Pending on
<br />❑ Pausnpar
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />a
<br />n, but pgnent within 42 days of death
<br />❑ Not propmre
<br />SWol❑
<br />❑ � ❑roved not w debnNnetl
<br />Ped"bU"
<br />❑a p� Not Ins pregnant 43 yew days to t ybefore d
<br />❑ Other (Specify)TO
<br />COMPLETE CAUSE OF DEATH?
<br />❑ Unknown N pregnant within the post year
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, form, street, bctory, office building, construction sib, ate. (Specify)
<br />tg
<br />22d. INJURY AT WORK?
<br />DESCRIBE HOW INJURY OCCURRED
<br />O
<br />❑ YES ❑ NO
<br />re.
<br />22f. LOCATION OF INJURY - STREET S NUMBER APTAO. CrryrrOWN STATE ZIP CODE
<br />23s. DATE OF DEATH (Mo„ Day, Yr.)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />S June 14, 2014
<br />S
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />OZ June 16 2014 05:50 AM
<br />< ,
<br />E the
<br />. To b bat of my knowledge, death occurred at the Unto, , dab and planso
<br />24e.
<br />Etine
<br />Oa caro bab of eeantinatlont anNar bvatlgMbn, M my apkdoa dsaM seauwee M
<br />10 and dusto tins caws(s) stabd. (algnabrered T"
<br />mm, data and place and dw b the causes) stated. (signature and TW)
<br />Chad Vieth, MD
<br />~ a
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />26s. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN
<br />❑ YES ® NO
<br />Not Appikable N 26a Is NO a YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS Of CERTIFIER (Type or
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE-
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />01, J6June
<br />17, 2014
<br />
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