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STATE OF NEBRASKA
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<br />Nflillt:< TSS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, • IT
<br />'CERTIHES ° 'HE •DOCUMENT BELOW TO BE A TR�tJE COPY OF THE ORIGINAL RECORD
<br />. ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECQRD$:QFFICE, WHICH IS THE LEGAL DEPOSITORY:FOR:::VITAL<RECORDS
<br />.......................
<br />......................
<br />O4SSLtA1li"CE
<br />12/20/2016
<br />RASKA
<br />202403259
<br />STANLEY S. a a PER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND.
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OFIiEALTH AND HUMAN SERVICES
<br />CERTIFICATE, OF DEATH
<br />DECEDEMT.'S-NAME (First, •MIddle, Last, Suffix)
<br />►.:perry • Elmer •Brannan
<br />tIerrrAab
<br />TORY, OR FOREIGN COUNTRY
<br />maha, Nieb:raska::
<br />SOCIAL SECURITY NUMBER
<br />50550.-558.3.
<br />Ii; FAc4111Y:NAM E (If not ItMttWtion, give street and number)
<br />Kearney•Reglor1dlMedical Center
<br />CITY OR TOWN OF DEATH (Include Zip Code)
<br />,;::..Kearney 68.845,.:.::•
<br />RESioNca-STATE
<br />Nebraska_:.; .......,,...: >:
<br />MEET "AND NUMBER
<br />'
<br />810 Cottonwood Street
<br />9b. COUNTY
<br />Hall
<br />BIRTH
<br />AL STATUS /I1,T.:;T(ME OF DEATH Married 0 Never Married
<br />Mafried, but;selsarlded,;;;• 0. Widowed 0 Divorced 0 Unknown
<br />31. FATHER S.NAME (First; Middle, Last, Suffix)
<br />Elmer Elsworth Braman
<br />r.ER IN U LARMED FORCEST Give his of service If Yes.
<br />'es;. No,..or 044 N0.
<br />15 METHOD OF:DI:SP ii1ON
<br />j 8url� • '13 DiAiiiton
<br />• 0 Cremation 07 Entombment
<br />Q ertto .a' XE
<br />.. . Olh .. {$Peoffy)
<br />5a.AGE.:: Last:Birfhday;
<br />liiti UNDER:::1 YEAR
<br />2. SEX
<br />Male
<br />MOS...
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL Eti Inpatient
<br />0 ER outpat)ent
<br />C3 D0A
<br />crry on 'room
<br />Wood River
<br />5c. UNDER 1 DAY
<br />1
<br />HOURS
<br />MINS.
<br />3 DATE DEA'$H I
<br />Decevnber 11,
<br />6. DATE OF $IR7H<i
<br />duhr 12,
<br />•
<br />OTHER 0 Nursing HonmeILT
<br />0 Decedent's
<br />0 Other (S )
<br />8d. COUNTY OF DEATH •
<br />Buffalo
<br />9e. APT. NO.
<br />91. ZIP CODE
<br />68883
<br />tOb. NAME QF :SPOUSE: (fleet,... Middle, Last, Sufnx) If wife, phre aatdea rtiixte:.
<br />Darns Mlll(an
<br />t2 MOTHER'S -NAME (First, Middle,
<br />Nevella Sloan Honaker
<br />14a. INFORMANT -NAME.
<br />Dona �TBtrtan
<br />18a. EMBALMER -SIGNATURE
<br />Spencer Kuhl
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION.
<br />Cameron Cemetery
<br />Ts. FUNERAL HINIE'NAMB AND MAILING ADDRESS (Street, City or Town, Steto)
<br />ADfel'Fulteta. Horne. 1123 W. 2nd. Grand Island. Nebraska
<br />16b;LICENSE NO.
<br />1339
<br />CITY I TOWN
<br />Wood River
<br />Maiden Surname).
<br />CAUSE OF DEATH (See instruct)opa, and examples)
<br />PART % Ester tlta:cliain of s* encs• mamma, injuries, or complications -that directly cauaad the death Ott NOT .nter terminal event. such as carder arrest,
<br />rrutp+naory arrest x ycetr*Fu1*r fibrillation without showing the etiology. Do NOT ABBREVIATE Enter only ene latae pre a *11* Add additional lines if naCesaary.
<br />IMMEDIATE CAUSE:
<br />CAUSE (Pixel ,• a)Cardiopulmonary Failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br /><b) Coronary Artery Disease
<br />DUE TO; OR AS A CONSEQUENCE OF:
<br />Eider the UNOENt.VING CAUSE C)
<br />eve
<br />{lddite 1:#00Y:t4 itgtY9tad ; imsieevl8ntl;in death) ':::Du
<br />8,' PA
<br />TO, OR AS A CONSEQUENCE OF:
<br />R SIGNIFICANT CONDITIONS-Condltions contributing to the death but not resulting In the underlying cause given in PART L
<br />n piet:year
<br />e of death
<br />ant; but pi'sgrnent within 42 day* of death
<br />ot:t fit prsena**t4$ days to 1 year before death
<br />egni'fAhh
<br />a p f the past Oaf
<br />2a. DATE OF ¥JURY (Mo., Day, Yr.)
<br />21a. MANNER OF''DEATH
<br />® Natural 0 Homicide
<br />ide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could!tet be determined
<br />22b. TIME OF INJURY
<br />21b. fF Tt2ANSPORTATION INJURY
<br />0 DrF/erbOperator
<br />0 Passenger
<br />0 pedestrian
<br />• c 11.*::tst»cifY)
<br />14b. RRLJtifONSt4lP
<br />SDOU
<br />t8c. DATE"(Mo.j
<br />December 17
<br />APPROX#MA'TEc iN
<br />deatrr
<br />'Bt.
<br />19. WAS MEA!::
<br />OR CORONER OONTACTEI
<br />21c. WAS AN AUTOP
<br />0 YES
<br />21d. WERE AUTOPSY FINDINGSAVA14ABLE
<br />TO COMPLETE CAUSE OP MATF
<br />El NT$
<br />22c, PLACE OF INJURY -At home, farm, street, factory, office building, construction!?
<br />DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OF !HAIRY • STREET 8, NUMBER, APT.NO. CITY/TOWN
<br />tis. DATE OFDf.ATH (Mo., Day, Yr.)
<br />DeCenlber 11, 2016
<br />p DATE ele:NED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />December 13. X016 11:41 PM
<br />edits, death occurred at the time, date and place
<br />the eauae4af Mated. 4Signature and Title)
<br />'_ loin, MD
<br />D(i?"r(kBACQG Oat6N'rRiBUTE'TO THE DEATH? 26a. HAS ORGAN OR TISSU4 :DONAIRCI BEEN CONSIDERED?
<br />�I YES Q Ne ®=PROBABLY 0 UNKNOWN ❑ YES iia; N0
<br />NAME,11ri.E AND ADDREBSOFF CiRTlP)ER.(Type it Print
<br />8tedley A,>8oh9,,;MO, 211 W 33rd Street, Kearney, Nebraska, 68845.....
<br />STATE
<br />.24a. DATE SIGNED (Mo., Day, Yr.)
<br />¢c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b, TINE
<br />24d. TiME
<br />2M. On the basis of saunlnadon and/or IwestlgatIon, in cap a
<br />the time, date and place and due to the camels) seals:l
<br />141SI041URE�07i
<br />tib. WAS
<br />Not
<br />28b. DATE FILED
<br />December 14, 2016
<br />
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