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rn C) n _ 17 C C�/f `ua p -i* p N M y C) C7 PIZ c D CAD -i N In G2 � i, '� rn -Zi m O CD -*T o N C_` CD M M D r � r � 00 Ca GO co CD Cn v v cla cn v' p Lots One (1) and Two (2), Block Four (4), in the Third Addition to Cairo, Hall County, Nebraska, WHEN THIS COPY CADS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND Ht AN S9gWCES - SYSTEM, IT CERTMS THE BELOW TO BE A TRUE COPY OF THE ORIGINAL Redbotpowfto 1WH _ THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SEA 0 JS' THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE _ JAN 16 2001 200408831 = j011LEYS COOKER ASS/STANX STATE RWG/STI�fAR _ . _ LINCOLN, NEBRASKA HEALTH AND HUMAN SERVM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES IM4ANCE ANDSUPPORT VITAL STATISTICS CFRTIFICATF nF nFATi-i -- Interval oetween onset and death PART ,al Natural causes unknown DUE TO, OR AS A CONSEQUENCE OF Interval between onset -i r, IN I DECEDENT -NAME FIRST MIDDLE LAST 2 SEX 3 DATE OF DEATH 'Mnnln Dav Ye ,,I Edna Maxine Brunda a Female December 4 25. WAS CASE REFERRED TO MEDICAL 4. CITY AND STATE OF BIRTH I fnol in USA. name countrv,i S. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH �Afonlh. Day. year) EXAMINER OR CORONER Lincoln, Nebraska D's 1 81 5c HOURS MINS �^ 29 1919 t 1Cl 7 , Sb MOS DAYS ' 7. SOCIAL SECUR7IY NUMBER 8a PLACE OF DEATH 26b DATE OF INJURY /MO. Day. Yr) 506 -28 -8551 HOSPITAL. ❑ Inpahent OTHER ❑ Nursing Home Accident � Undetermined ❑ ER Outpatient ® Residence Bb. FACILITY - Name rd nor ristiturron, give street and number/ 501 -Nubia ❑ DOA ❑ Other �Spec',ty' _ M 6c. CITYY. TOWN OR LOCATION OF DEATH 116. INSIDE CITY LIMITS Be COUNTY OF DEATH 26e. INJURY AT WORK Cairo Yes R] No ❑ Hall ElHomicide Investigation 9a. RESIDENCE -STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zp Code; 9e INSIDE CITY LIMITS 27a. DATE OF DEATH IMO.. Day. Yr) Nebraska Hall Cairo 501 Nubia 68824 Yes [I No ❑ 10. RACE - leg. White. Black. American Indian 11 ANCESTRY le.g Italian. Mexican, German. etc! 12. ❑ MARRIED WIDOWED 13 NAME OF SPOUSE df wife give maiden name/ ( dec ) y } etc.! (Spea�l�yJ,j'� y. " " -iite ISpealypl "" "'rican NEVER DIVORCED MARRt Leonard George Brundage 28d, PRONOUNCED DEAD /Noun 14a. USUAL OCCUPATION IGrve kind of work done during mosr 1 BUSINESS INDUSTRY 15. EDUCATION I8pecdy only r hest grade completed) of working life. even it retired/ Homemaker home Elementary1 0 ondary (0 12) College 11 -d or 16. FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME M Drian Edgar Stoe er Edna Watson • 18. WAS DECEASED EVER IN U.S ARMED FORCES 19a. INFORMANT -NAME 28e. On me basis of examination and! vestigation, m my 4elmo a th occurred at )Yes. no. or unk.l Ilf yes give war and tlates of serv¢esl iio Darrel Brundage 19b. INFORMANT MAILING ADDRESS STREET OR R.F D NO CITY OR TOWN. STATE. ZIP) cause(sl stated. 508 S. Thebe St. Cairo NE 68824 the time, date and place and eI at +� , -,t- �� 20. E B MER - NAT LICENSE N 21 a. METHOD OF DISPOSITION 21b. DATE _ 21c. CEMETERY OR CREMATORY NAME (Signature and Tide I �� x❑ Burial ❑ Removal 12/8/0 Mt. Pleasant Cemetery ❑ YES ❑ NO ®' UNKNOWN 22a. FUN' AL HOME NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE fel Funeral Home ❑Cremation ❑ ponaodn Cairo NE 22b. FUNERAL HOME ADDRESS ISTREET OR RED NO CITY OR TOWN. STATE. ZIP) 32b. DATE FILED BY REGISTRAR /Mo. Day. Yr/ 411 West 11th P.O. Box 126 Wood River NE 68883 Interval oetween onset and death PART ,al Natural causes unknown DUE TO, OR AS A CONSEQUENCE OF Interval between onset -i r, IN r I DUE TO. OR AS A CONSEQUENCE OF Interval between onset mo deer, (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PREGNANCY II IN THE PAST 3 MONTHS, EXAMINER OR CORONER )Ages 10 -54) Yes No Yes No Yes No 26a. 26b DATE OF INJURY /MO. Day. Yr) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident � Undetermined M El Suicide � Pending 26e. INJURY AT WORK 26f. PLACE OF INJURY - At home. farm. street. factory o ice bmldrig, etc rSpeciy) 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE ElHomicide Investigation Yes No ❑ ❑ 27a. DATE OF DEATH IMO.. Day. Yr) 28a. DATE SIGNED (Mo.. Day Yr.) 28b TIME OF DEATH y } i c Y 27b. DATE SIGNED /Mo.. Day. yr I 27c. TIME OF DEATH 8c PRONOUNCED DEAD IMO.. Day, Yr.) 28d, PRONOUNCED DEAD /Noun 8F� °2 M $"£'�� M 27d. To the best of my knowledge. dearn occurred at the time, date aril place and due to the 28e. On me basis of examination and! vestigation, m my 4elmo a th occurred at O o cause(sl stated. the time, date and place and eI at +� , -,t- �� I (Si nature and Title Do (Signature and Tide I �� 19, 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30-a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b AAS CONSENIr GRANTED? ❑ YES ❑ NO ®' UNKNOWN ❑ YES lid NO ❑ YES Ej NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) IType or Print) 1 Dep R Miller HCSO 131 S.Lociistli Grand T-,Iqnd NE 68801 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR /Mo. Day. Yr/ DEC 14 2 r I