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. . <br /> g9• 1(�4'799 <br /> �9'-�0��99 <br /> WFEN 1FIS CQPY CAI�s 11#RA13ED SEAL OF THE NEBRA3KA HEALTF/dND•M�1!IAN SERV/CES <br /> SYSTEIY�IT CERT�S TF�BELOW TO BE A TRUE COPY OF THE OR/O/l1�7�EE��![p/LE W/TH <br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL _ ;�y/�//��g <br /> THE LEOAL DEPOSITORY FOR VITAL RECORDS =:--e-- `- - -- <br /> ATE OF/33UANCE __- _ �-i -�y�_����' <br /> I�PR ' =_-::������- ._ - <br /> 16 1999 : �r�.��PER <br /> =-,iE�4�s`�1'�i1iP1'sr�ITf I���RAR <br /> UNCOLN,NEBRASKA HEALTH"P1VD Wl/�AN SERV/(�3�STEM <br /> S'fATE OF NEBRASKA-DEPAR7'MENP OF HFALTH AND F{Ulv`u4At g�jLVq�[CE A�SUPPORT <br /> VITAL STAT[STICS -- _ _ -_-- — <br /> CERTIFICAT'E OF DEAT�=�' --�=� <br /> 1 DECEDENT�NAME FIRST MIDDLE LAST 2 SER J 3 DATE OF DEATH /MOnlh.Day Yearl <br /> Merle Clarence Brundage Male April, 9, 1999 <br /> C CITV qND STATE OF BIRTH plrrolin USA..name counfryl Sa.AGE-Last BIO�day UNDER 1 VEAR UNDEP 1 DAV 6.DATE OF BIRTH (MOnlh.Dav VearJ � <br /> Cairo, Nebraska (Yrsl O� Sb MOS � DAVS SC HOURS MW$ March 1 / � 171 / <br /> 0 <br /> 7 SOCiAL SECURTIV NUMBER 8a. PLACE OF DEATH - <br /> . 5 0 7-14-317 2 MOSPITAL �inDatienl OTHER ❑ Nursing Mome <br /> Bb FAGLITV-Name p/rro�msliNlron,givesbeelarrdnumDer� � EROulpa60m � Residence <br /> � St. Francis Medical Center ❑ 004 � a„e„��,ty, _ <br /> Bc Ciry TOWN OR LOCAiiON OF DEATH Bd INSIDE CITV LIMITS 8e COUNTY OF DEATH <br /> Grand Island ,.85 � No ❑ Hall <br /> 9a RESiDENCE-STATE 9b COUNTY 9c.CITV,TOWN OR LOCATION 9tl.STREET AND NUMBER /Inciuding2�p CodeJ 9e INSIDE pTY LIMITS <br /> Nebraska Hall Cairo 212 S. Suez �es� No❑ <br /> t0.RACE�(e.g.,Whlte.Black.Ame��can IrMian. 11.qNCESTRV�e.g..Italiaq Me�ican.German,elcl t 2.�MARqIED ❑WIDpWED 13 NAME OF SPOUSE /ll wrle.grve ma.den name/ <br /> e"'G��Ifi'Yte 'S°�°'"'En lish <br /> g NEVER DIVORCED Mary SCOtt <br /> MARRI <br /> 7 aa.USUAL OCCUPATION /Brve kiMo/woik dpne during mpsl 14b KIND Of BUSINESS INDUSTRY 15.EOUCATION �Spenly only Mqhesl gra0e compleled� <br /> o/ trmg h1e,evan dieNred) Eleme�aoor Secontlar 10-�2 <br /> `�`arming Agrieulture Y � Coilege��.ao,�-, <br /> 16 FA7HEF�NAME FIRS7 MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br /> Clarence Brundage Bertha Orndoff <br /> �8 Wo5 DECEASED EVERIN U.S ARMED FORCES? t9a.WFORMANT�NAME — <br /> I�e�.�p y�unk.� ;�I y?5.�rve war anG tlales o15arnC83� <br /> NU Mary Brundage <br /> � 19� 'NFOAMANT MAILING ADDFESS ISTr7EET OR R.F.D NO..CITV OR TOWN.STATE.ZIP� ---- <br /> 212 S . Suez Cairo, Nebraska 68824 <br /> 20 EMBALMER-SIGNA7URE8LICENSENO � .�!�� 21a MEiHODOFDISPOSiT�Oh 21b.DATE 2tr CEMETEFVORCREMATURV�NAME - <br /> C 1�z� b �' <br /> _ �B��,a� �Removal rll. 12 199 Mount Pleasant <br /> 2?? �U R HOME-NAME / 21tl CEMETERV OR CREMAiORV LOCAT�rIN CITV OA TpWN STATE <br /> Apfel Funeral Home �Crematan ❑��a����� Cairo, Nebraska <br /> 2Tb FUNERAL MOME ADDRESS �STREET OR R.F.D.NO.CITV OR TOWN.STATE.ZIP� �� —� <br /> 411 West llth St. , Wood River Nebraska 68883 <br /> 23 IMMEDIATE CAUSE IENTER ONLV ONE CAUSE PER LINE FOR ia�Ib1.ANO lcll I In�erval Delween onsel an�tleair�. <br /> PART <br /> I <br /> ' Respiratory Failure. � <br /> 'a' 4 da s <br /> � DUE TO.OR AS A CONSEOUENCE OF Congestive Heart failure and Pneumonia supraimposied fOn I���n�sei ano aeam <br /> seta,ere COPD. � ' � <br /> DUf_70.OR AS A CONSEOUENCE OF� I �Inle�a�be�wi�}r��set ana�eam <br /> ��� Atherosclerotic Coronary Vascular Disease. � <br /> � Years. <br /> PARTHER SIGN IC ONDI NS-ConOitronS/C�ontrLib�uling b�yt�e�Tdef7a�th bm not�ela�ea PART III iF FEMALE W nS THERE A 2a AUTOPS� 25.WAS CASE REFERRED TO MEDICAL <br /> ecen� ��, �evere l.Hl:/ VL/ry�� PfiEGNANCY IN TME PAST 3 MONTHS� <br /> E7(AMINER Ofi CORONER� <br /> IA9es i0�5a) Ves No ves No Ves No <br /> z6� 26D DA7E OF INJURY /MO_Day.YcJ 26c.HOUR OF INJURV 26d.DESCRIBE HOW INJURV OCCURREO <br /> � Acc�Oem � Untle�erminetl N/A <br /> M <br /> � Swade � Pentl�nq 26e INJURV AT WORK 26f PLACE OF INJURV-Al lwme.�a�m.street.lactay 26g.LOCATION STREET OR RFA.NO. CITV OR TOWN S7ATE <br /> ❑ ❑ ❑ otlice buAairg.etc /Speciy/ <br /> Hom�utle Invesuqauon yes No <br /> 27a DATE OF DEATH /Mo.DaY Y�J 28a DA7E SIGNED /MO.Day ✓�! 28b TIME OF DEATH <br /> � ��� � <br /> �N °'�z M <br /> �c J 27b DATE SIGN D /MO..Day.Vrl 27c TIME Oi DEATH E i�J 2& PqONOUNCEO DEAD /MO Day.Yr/ 2Btl.PqONOUNCED DEAD /HOUn <br /> g°'° �- `Z- '''` 11: `55 A. M ��=o <br /> °a 27d io�he Dest oi m krwwied e.ee rr o�o M <br /> Y 9 edat thB ti Uat rW ace and tlue to the �� 28e On the Dasis ol exammauon antl or invesugauon,in my opmion tleath occurretl ai <br /> causelsl statetl. o o Me ume.date antl pace ane due to the causels�statetl. <br /> i5�nature and Title)► ISi nature anC Title � <br /> 29 DID TOBACCO USE CONTRIBUTE TO THE ATH? 30. HAS ORGAN OR TIS DpNAT10N BEEN CONSIDERED� 3p.D WAS CONSENT GRANTED� <br /> �vES � NO � UNKNOWN � VES I JV NO � YES NO <br /> y�—�. <br /> 3� NAME AND ADDRESS OF CERTIFIER IPHVSICIAN,COfiONER�S PHYSICIAN OR COUNTY ATTORNEVI �Type aPriml <br /> Dr. Steven L. Husen M.D. 2116 W. Faidley Grand Island NE 68803 <br /> 32a REGISTRAR 320.DATE FILED BV REGISTRAR /Mo.Day Yr.� <br /> APR 15 i99� <br />