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<br />C� STATE OF NEBRASKA ),
<br />S�411111111IJ"°
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<br />:WiNdkuttiOi.,00 CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />aS A TRUE COPY OF TIAL ORIGINAL RECORD ON FILE WITH THE IVEERASI`A DEPARTMENT OF HEALTH AND
<br />,. LIMANSERVICCS, NATAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />..................... ...........
<br />DAT IS$UA1
<br />716103
<br />t tIMLiOLN, NEBRA
<br />202303858
<br />/10
<br />BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 OlaoEDENT'$4'VAME (Pira
<br />I Br�lminutid
<br />NO tattoo,TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Middle,
<br />Suffix)
<br />Grand Island Nebraska
<br />SOcateS URITYNUMBER
<br />'507424)469
<br />0469
<br />FACILITY NAME (t[ dot institution, give
<br />Bs AGE - Lastekthday:
<br />(Yrs.)
<br />75
<br />2208 Woodridge Mace
<br />8a C{TYY)R Tf WN OF DEATH (include Zip Code)
<br />ar..airt€ Islalid 8880 !
<br />SitENCESTATE
<br />Natrraska
<br />TANCWNUMR
<br />Uoddrid(#e place
<br />1119611TAL $'.ATOS AT TWE OF DEATH ® Married 0 Never Married
<br />LI. Married, but senstateitQ Widowed Q Divorced 0 Unknown
<br />AT .ER'SNAME (Plrsh Middle, Last,` Suffix)
<br />abert Earl Brunlmund
<br />13 EVERiN U$rARMED FORCES? Give dates of service if Yes,
<br />(Yes, No, or Unk.) No
<br />;5b.::UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />8c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />8a.:PLA/ E OF; DEATH
<br />HOSPITAL Q Inpatlrutt OTHER 0 Nursing 1laenalLTC
<br />u LR/Outpatient Ea s Home
<br />Q DOA Q Other (Speety)
<br />3. DATE OF 1 ATili fie
<br />June 27, 2021.
<br />23 0
<br />8. DATE OF 13419114 (Mo.,
<br />January 2p.,...11148
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hail
<br />9e. APT. NO.
<br />u 16, METHOD OF DISPOSITION
<br />Bunny Q Clonal%
<br />meBli f Q Sntorrtttment led, CEMETERY, CREMATORY OR OTH LOCATION CITY / TOWN
<br />...........(Styy)
<br />Westlawn Cemetery
<br />Ob. NAME OF SPOUSE (Firs
<br />Debbra Dee Bonsack
<br />91. ZIP CODE
<br />68801
<br />Middle, Last, Suffix) M wife, give maidenntible-
<br />12. MOTHER'S -NAME (First,' Middle, Maiden
<br />Aiidrt v Mae Bayne
<br />14a. INFORMANT -NAME
<br />Debbra Dee Brummund
<br />16a. EMBALMER -SIGNATURE
<br />Kelley;D Sheridan
<br />16b. LICENSE NO.
<br />1439
<br />17a. FU NERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />AI I"anise I~unera(,Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />1413 RE144TiONS*P"=-
<br />Wife
<br />16c. DATE+
<br />July 4,
<br />Grand Island
<br />tebraska
<br />nter tM chain of " disgme, injuries, lir comp icatlonsdhat directly caused She death. DO NOT enter terminal events abaft as cardiac arrest,
<br />e1r
<br />emus, or sonstestertiefaadat wkn.ut showing the otology. DO NOT ABBREVIATE. Enter only enecetuse on a tits. Add additional lines If necessary,
<br />IMMEDIATE CAUSE:
<br />rite a) Chronic systolic congestive heart failure
<br />at condition moutons
<br />lE TO, OR AS A CONSEQUENCE OF:
<br />I)Coronary artery disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Eaue iwik tipOONdOPitit?' c)
<br />(tMs se Cr iniurglhad lanNte
<br />we swatsnsulting In death)
<br />tA6T'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />18. PAR 1 II O1:.91&061691DANT CONDITIONS.conditiona contributing to the dedth but not rasulbng t. the uhderlying cause given tet PART L
<br />n:
<br />19. WAS
<br />OR
<br />❑v55
<br />itl4t.rNae+l cut paS$iiatit rdthin 42 days of peach
<br />Q 1401 Pregnant, but pnsgaat43 to 1 yMr before death
<br />"Pt!
<br />a U Pregnant edadn the -past year
<br />92s DATE C)F iNJ URYIMuta : Day Yr.)
<br />Y AT WORN
<br />YES ,Q NO..
<br />21a. MANNER OF DEATH
<br />®Natural Q HOMNide
<br />-..Q Accident 0 Pendtilp Invdetlga ad
<br />Suicide
<br />0 Could Aron be determined
<br />21:b IF TRANSPORTATION INJURY
<br />DnvaNOperator
<br />CIPassenger
<br />Pedestrian
<br />Q Other (Specify)
<br />22b. TIME OF INJURY
<br />22c. PLACE. F IN.IURY Alit
<br />210. WAS AN
<br />0 vas
<br />21d, WERE AU
<br />TQCOMPL
<br />Q YES Q NO
<br />rat, street, factory, office building, Construction
<br />E HOW INJURY OCCURRED
<br />REET & NUMBER, APT.NO. CITYITOWAi
<br />a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 27 2023
<br />STATE
<br />23b..DATE SIQt*D (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />2G23 06'50 PM
<br />23dbxa.txa betel of mytuawledge, dads occurred at the thne, date and place
<br />ltuddwtathaajiuse(s) stated, (Signature and Tme)
<br />Chad Vieth, MD
<br />CC0 USE CONTRIBUTE TO THE DEATH?
<br />f E PROBABLY ® UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD' (Mo., Day, ti*r.1
<br />�Zkd TIME
<br />tie. 6a the blab of exeminatton anldler ituiesigation, In my orinWn Matt
<br />ills Unto, i ate and place and due to the cause(s) stated. (Signature add T)t e) f
<br />26a. HAS ORGAN t2R TISSUE. DONATION BEET
<br />Q YESC;NO
<br />ID ED?
<br />t 16.mtce AND AD KESS OF CERTIFIER (Type or Print
<br />C#Iad
<br />Vieth MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b.WAS CONSENT tB .:B(!?
<br />Not Applicable If 26a Is N4f Y
<br />28b. DAT! FILED 13N SSS„ flay, the
<br />June 30, 2023
<br />
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