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f4ssryy ,�„ t�tawrlt)�` STATE OF NEBRASKA
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<br />WHEN THIS CpPYCARRIE$ THE RAISED .SEAL OF SATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUECap : F THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />DA TE;OF ISSUANCE'
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<br />LINCOLN,.NEBRASKA
<br />202500075
<br />AL l 314rr.,+'I ii'k,et oet
<br />SARAH 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 DE$i«DENT'S r1AME (Fir) Middle, Last, Suffix)
<br />St etyt Anr Brundae
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Che:yenne;; lNyoiT i 1q'.
<br />i SOCIAL SECURITY
<br />505.7096"48.
<br />5a. AGE - Last Birthday-
<br />(Yrs.)
<br />73
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />3222 Paradise Dr
<br />so Cr OR TOWN.OF DEATH (Include Zip Code)
<br />Hastings 6801
<br />9a RESIDENCE STATE
<br />9b. COUNTY
<br />Nebraska Adams
<br />Sd STREEYANDNUM$ER ..
<br />3222 Paredlee Dr
<br />1
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />❑ Married butsepardted ❑ Widowed 0 Divorced ] Unknown
<br />'11 PAThER S-NAME (first Middle, Last, Suffix)
<br />Elmer J O Neill
<br />13. EVER"(N U.S. ARMED FORCES' Give dates of service if Yes.
<br />(Yes, No, or'Unk.) NO
<br />1!i M ETttO1 QF D.ISPt 7SIT1EM1
<br />❑ Brfrial ❑13onatloh
<br />® Cremation ❑ Etttotnbmunt
<br />❑ Removal • 0 Other (Specify)
<br />511. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, .PLACE OF DEATH'
<br />HOSPITAL ❑:Inpatient
<br />❑ ER/Outpatient
<br />❑;DOA:
<br />9c. CITY OR TOWN
<br />Hastings
<br />HOURS
<br />MIN,,
<br />1kr:11
<br />4 '14949
<br />3. DATE OF DEATH (MA Day Yr )
<br />October'27, 2024
<br />6. DATE OF BIRTH tMo., Day, Yr.)
<br />December 24 '€950
<br />OTHER 0 Nursing Home/LTC: ❑ /#aspics faciiffy
<br />Decedent's Home
<br />0 Other (Specify),
<br />8d. COUNTY OF DEATH
<br />Adams
<br />9e, APT. NO.
<br />9f. ZIP CODE
<br />68901
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Ronald Merle Brundage.
<br />12. MOTHER'S -NAME (First,
<br />Agnes . M Marvel
<br />14a. INFORMANT -NAME
<br />Ronald Merle Brundage
<br />lea, EMBALMR-SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />AND MA LING ADDRESS (Street, City or Town, State)
<br />.ffiAptei FUrleret;Home a05 N Bellevue, Hastings, Nebraska
<br />174 FUNERAL HOME NAME
<br />16b. LICENSE NO.
<br />Middle, Maiden Surname)
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF D� ATH (See instructions and examples)
<br />IS. PART I. Enter the chain of events--diseeaes, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest or ventrrcgtar fibrillation without showing the etbiogy. DO NOT ABBREVIATE. Enter only one cause on aline, Add additional lines if necessary.
<br />IMMEDIATE CAUSE: /
<br />at ga) Metastatic Small cell neuroendocrine cancer
<br />IMMEAtATE CAUSS (Fin
<br />diseasC t ddnditien<rev
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />S4quentia)..Ly.(letconditiona,.it...;_ b)
<br />arty; lesdllg t0 fhe GAttse Ilsted I
<br />::en.11rtE:e..
<br />tlUE TO, OR AS A CONSEQUENCE OF:
<br />aEnterth0UNORLYUYt/CAUSE"" C)
<br />(disease or Injury that Initiated ..
<br />4(re events resulting in death/ fUS TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />1S, PARTII OTHER::SIGNMF1r ANTCONDITIONS-Conditions contributing to the death but not:reaultingin the underlying cause given in PART I.
<br />History of au enocarcinorna of the Colon, chronic obstructive lung disease, diabetes mellitus type 2,
<br />2( IF FEMALE:;
<br />No pregnam
<br />❑ Prsgnanl al t
<br />❑ Not pregnant, but pregnant within 42 de of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown 4 pregnant wimtrrrae.past year
<br />2a RATE OP INJ1J£tY (I;ity' Day, Yr.)
<br />22d. INJURY AT WORRY
<br />rES ;:❑ NO
<br />22F LOCATION"t F
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />31:b.IPTRANSPORTATION INJURY
<br />Oliver/Operator
<br />:❑ PM 'enger
<br />Pedestrian
<br />❑ Other (Specify)
<br />IioE Oft -if LIMITS
<br />YES
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo:i pay, / ,)
<br />October 30 2024
<br />STATE
<br />.,Nebraska.
<br />17b;2lp:Coda
<br />6tif)41
<br />APPROXIMATE.NTERVAL
<br />onset tC d.(1t
<br />17 Months::
<br />19. WAS:NED
<br />OR CORON
<br />O YES
<br />:A4 EXAMINER
<br />R CONTACTED?
<br />21c. WAS AN AUTOPSY: PeRFO
<br />❑ YES 1 NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAU$E OF;DEATH2..,
<br />❑ YES ❑Ni,I
<br />22c. PLACE OF INJURY-At.home 7arm, street, factory, office building, construction site, etc. tSpeCIfy►
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />INJURY STREET s NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 27, 2024
<br />CITY/TOWN.
<br />00. DATE,SiGNED (Mo., ©ay,.Yr.) 23c. TIME OF DEATH
<br />s a.bber 2 t24 02:42 PM
<br />d TAthatipat df my krrowledge, death occurred at the time, date and place
<br />and dile to thei£aiiae(e) stated. (Signature and Title)
<br />Julie Fletcher, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b, TIME OF DEA
<br />Z rn
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<br />24C, PRONOUNCED DEAD (Mo„-Day, Yr.) 24d. TIME PRONQUNQ.
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<br />25 DID TOB4
<br />Q uSE CONTR BUT,E TO THE DEATH?
<br />let YES ND ❑ PROBABLY 0 UNKNOWN
<br />27. NAMLk TITLE AND ADDRESS bF CERTIFIER (Type or Print
<br />Julie Fletcher, MD, 715 N St Joseph Ave, Hastings, Nebraska, 68901
<br />•
<br />28a:REGISTRAR $SIGNATURE O,t"
<br />�._ t_./IQ /"I �a err rvcr
<br />24e. On ttie basis of examination and/or investigation, in my opinion dealh Ofotiee
<br />the time, date and place and due to the cause(s) stated. (Signature and COO
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED
<br />❑ YES ®NO
<br />7� 26b. WAS CONSENT GRANTS .
<br />Not Applicable if 26a is NO ❑ YES 0 HO
<br />28b. DATE FILED BY REGIS
<br />November 4, 2024
<br />2oF2
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