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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />13E TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />7/6/2023
<br />LINCOLN, NEBRASKA
<br />202404251
<br />SARAH BOHNENKAMP 7
<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 DECEDENTSHNAME iFirrst, Middle, Last, Suffix)
<br />Grail E Btummur d
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7, SOCIAL SEOURITr NUMBER
<br />y�rLi Li�VWait? ...
<br />8b. FACILITY-NAM'E (U •got Institution, give street and number)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />2208 Woodridge .Place
<br />8c.<CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9i'RESiDENCE-STATE
<br />Nebraska
<br />d..STREET AND NUMBER::
<br />2208 Wod )ridge Place
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHERSNAME (Ftratt,. Middle, Last, Suffix)
<br />Robert Earl Brummund
<br />13. "EVER iN US ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15; METHOD OF DISPOSITION
<br />f Bitor0 ❑ Donation
<br />Cremation> ❑ Entombment
<br />❑RemovaF ❑Other(Specify)
<br />75
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />F.I0Sinwn4, fl inpatient
<br />❑ ERIOu patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 08781:
<br />3. DATE OF DEATH (Mo., Day Vrr:;
<br />June 27, 2023
<br />6. DATE OF BIRTH (Mo., Day, W.)
<br />January 28 19:48
<br />t)THER ❑ Nursing Home/LTC
<br />El Decedent's Home
<br />❑ Other (Specify)
<br />18dCOUNTY OF DEATH
<br />.
<br />Hall
<br />Ile. APT. NO.
<br />1Ob. NAME OP SPOUSE (First, Middle, Last,
<br />Debbra Dee Bonsack
<br />9f. ZIP CODE
<br />68801
<br />9,j INSIEIE CITY LIMITS;
<br />Yes [ :rte
<br />Suffix) If wife, give maiden name
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname
<br />Audrey 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 />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery Grand Island
<br />;: 17a. FUNERAL:HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Alt'iiiithsinnefECHOme, 2929 S. Locust Street, Grand Island, Nebraska
<br />14b. RELATIONSHIP TO DECE`IENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />July 1, 2023
<br />STATE
<br />Nebraska
<br />t7b Zip t ode ::. .
<br />• 88801
<br />CAUSE OF DEATIC Sot:161N . • n ; red exam • Ie
<br />E '13. PART I. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br /># respiratory angst, or veMncular fibrillation without showing the etiology. 00 NOT ASOREVIA'; 2. Enter only one cause on a lune. Add additions! Ines it necessary.
<br />IMMEDIATE CAUSE:
<br />1MMEDIATECAUS£ (Eisai a) Chronic systolic congestive heart failure
<br />l: disease eredndition resulting >'
<br />ro.
<br />tg Sequentially list cbndigons, If
<br />any, leading to tha.cause )s
<br />te
<br />d
<br />on Ulla a
<br />£nterth4 UNDERt,YINt AUSE
<br />(dis aaedr Inja ytHn inlNeteil
<br />s"r the events resulting in death)
<br />LAST. d)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Coronary artery disease
<br />APPROXIMATE INTERVAL
<br />onsetto.dealh
<br />Month(C
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />18 :#CART 11, OTI tER S
<br />hypertension .
<br />onset to death`
<br />Years
<br />onset to death
<br />onset to death
<br />WONT CONDITIONS -Conditions contributing to the..death but not res
<br />L1F.FEMALE::.:.
<br />..Not pregnant wWtin past year
<br />❑ Pregnant at gine of loath '
<br />❑ Pitot eregneM, but pregnant within 42 days of death
<br />Not pregnant, but pregnant 43 days tot year before death
<br />Unknown if pregnant wtMin the pest year
<br />22a DATE OF t('(IURY (Mo ;:Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF. DEATH
<br />El Natural 0 Homicide
<br />0 Accident 0 Pending Inveatigallon
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE DF INJURY•
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ting in the u
<br />derlying cause given in PART 1.
<br />21b:::IF TRANSPORTATION
<br />0 Driver/Operator
<br />L..I Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />INJURY
<br />19. WAS MEDOL:EXAM)NE#t
<br />OR CORONER CONTACTED9'
<br />❑ YES®NO
<br />21c. WAS AN AUTOPSY PERFORMED /
<br />YESI NQ
<br />21d. WERE AUTOPSY PIN NGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />home, fans, street, factory, office building, construction site, eta;
<br />22f .LOCATION'QF INJURY.:STREET & NUMBER, APT.NO. CITY/TOWN
<br />hs:
<br />a.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 27, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />June 28.2023 06:50 PM
<br />23d. To#he beat of my knowledge, death occurred at the dme, date and place
<br />ens: due to the asUse(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED' DEAD
<br />24e. On Ira basis of examination and/or Investigation, In my opinion dsadt.04e4trad st
<br />the•tme; date and place end due to the cause(s) stated. (signature and Ti9a) •
<br />ts. DID TOBACCO USE. CONTRIBUTE TO THE DEATH?
<br />YES NO ❑PROBABLY El UNKNOWN
<br />27. NAME, TITLE'AND A DRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, Mb, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable N 26a Is NO [._t YES
<br />❑ NO::
<br />28a. REGISTRAR'S SIGNATURE
<br />a_ii 8.4/1_.Le.r4a.rp= _ T
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 30, 2023
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