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<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND~NtilMCn
<br />SYSTEM, IT CERnFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL BECORf) QN"Flt..E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/SfCSSEC.T/ON,.,WHK;HIS
<br />
<br />:~:::::ORYFOR ><TAL RECORD~ ~A!if!i:r'.
<br />
<br />12/13/2004 200 511411 A$SIST~NTSTATE'RllGj$tiMk
<br />LINCOLN, NEBRASKA HEALTH ANiJ:~NSERvt.fi!:~:~Sjd
<br />
<br />, c.:..",-.,,:.,~,. c .2,,(/ ..""
<br />STATE OF NEBRASKA- DEPARTMENT OF REALTII AND HUMAN S$Jq$:p,jIN~~'S.t#PoRT
<br />VITAL STATISTICS' -'..-" ,-"" "'e,. .', ., .-".,,- -
<br />CERTIFICATE OF DEATH -- -,' 4
<br />
<br />e.)"
<br />-~
<br />(....'j
<br />,)
<br />",
<br />
<br />1. DEC!;DENT - NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2. SEX
<br />
<br />
<br />6, 2004
<br />
<br />Geralyn
<br />4. CITY AND STATE: OF SIATH {II (lot In U.S.A.. "ame cOtJntryJ
<br />
<br />Donna
<br />
<br />Bruns
<br />
<br />Female
<br />
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURTIY NUMBER
<br />
<br />Sa. AGE. last Birthday
<br />IY".I 41
<br />
<br />uNDER, YEAR
<br />5b. MOS I DAYS
<br />I
<br />
<br />UNDER' DAY
<br />5e. HOURS MINS
<br />
<br />6. DATE OF BIRTH (MOnth. Day, Year}
<br />
<br />23, 1963
<br />
<br />8b. FACILITY - Name
<br />
<br />(If not institution, give street and nI,lmost)
<br />
<br />8a. PLACE OF DEATH
<br />HOSPITAL: 0 Inpa.tient
<br />o ER Outpatient
<br />o DOA
<br />
<br />OTHER" [Xl NurSing HOme
<br />
<br />o ResIdence
<br />~lhe'ISpeCdVl Ski lIed Care
<br />
<br />505-64-0467
<br />
<br />Saint Francis Skilled Care Center
<br />
<br />16, FATHER - NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />
<br />Hall
<br />
<br />Be. CITy. TOWN OR LOCATION OF DEATH
<br />
<br />Grand Island
<br />
<br />8d, INSIDE CITY LIMITS 8. COUNTY OF DEATH
<br />
<br />10. RACE. (e.g.. White. Black. American Indian.
<br />e'e.IISpeeilyl whi te
<br />
<br />
<br />ge INSIDE CITY LIMITS-
<br />
<br />90, RESIDENCE. STATE
<br />
<br />Nebraska
<br />
<br />Yes IX] No 0
<br />
<br />11. ANCES1FW 19.9.. Italian. Me)(ican, German, atel
<br />ISpee'M Ameri can
<br />
<br />Ilf wife. give maiden name)
<br />
<br />Bruns
<br />
<br />t 4a. USUAL OCCUPATION IGive kind Of work dOne eluting masf
<br />of INorkmg 11(9. ever! if retir9d/
<br />Treasurer
<br />
<br />Church
<br />
<br />LAST
<br />
<br />MIDDLE
<br />
<br />MAIDEN SURNAME
<br />
<br />Donald
<br />
<br />Geraldine
<br />
<br />Schmidt
<br />
<br />18. WAS DECEASED EVER IN u.s. ARMED FORCES?
<br />IYes. no. or unk.l lit yes. glve war and dales of liiervice$l
<br />No
<br />19b. INFORMANT
<br />
<br />James Bruns
<br />
<br />MAiliNG ADDRESS
<br />
<br />ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIPI
<br />
<br />3031 Idaho Ave., Grand Island, Nebraska
<br />
<br />68803
<br />
<br />
<br />21,. METHOD OF DISPOSITION 21 b. DATE
<br />
<br />21 c. CEMET~RY OR CRt:::MA TORY NAME
<br />
<br />/ y~ '1071
<br />~ \
<br />All Faiths Funeral Home
<br />
<br />[XI Buri,l 0 Removal Decad::1er 10, 2004 Grand Island ci t
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN
<br />
<br />o C,em'lion 0 Do""'"'' Grand Island, .Nebraska
<br />
<br />
<br />22b. FUNERAL HOME ADDRESS
<br />
<br />ISTREET OR R.F.D. NO, CITY OR TOWN. STATE. ZIP)
<br />
<br />
<br />2929 S. Locust st., Grand Islarid, Nebraska
<br />
<br />23. IMMEDIATE CAUSE P
<br />PART .... ~ , <, ; No
<br />I ,al v'O V V;1 '-' vo..:..
<br />DUE TO. OR AS A CONSEOUENCE OF-
<br />
<br />68801
<br />
<br />
<br />~J2a,r-----
<br />
<br />
<br />Homicide
<br />
<br />Investlg~tlon
<br />
<br />26e. INJURY AT WORK
<br />Yes 0 No 0
<br />
<br />M
<br />261. ~~~u~~~~~~.y (t~W" farm, street factory
<br />
<br />
<br />I
<br />I
<br />I
<br />I
<br />I Interval between onset and death
<br />I
<br />I
<br />I
<br />I Interval between onset and death
<br />I
<br />I
<br />I
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />
<br />No X
<br />
<br />-
<br />
<br />Ib)
<br />DUE TO, OR AS A CONSEOUEONCE OF-
<br />
<br />--
<br />
<br />lei
<br />PART orHI;R SIGNI~ICANr CONDITIONS - Conditions contribul;ing 10 the death out not related
<br />
<br />II
<br />
<br />260.
<br />
<br />26b. DATE OF INJURY 11,10.. Day. Y'j 28e. HOUR OF INJURY
<br />
<br />D
<br />D
<br />D
<br />
<br />Accident D undetermined
<br />Suicide 0 Pending
<br />
<br />269. LOCATION
<br />
<br />STREET OR R,F.D, NO,
<br />
<br />CIfY OR TOWN
<br />
<br />STATE
<br />
<br />27" DATE OF DEATH IMa.. Day. Y'I
<br />
<br />28,. DATE SIGNED IMa.. Day, y,)
<br />
<br />28b TIME OF DEATH
<br />
<br />December 6,
<br />27b.
<br />
<br />2004
<br />
<br />E'~
<br />l~;>-
<br />8~g
<br />n
<br />~4
<br />
<br />TIME OF DEATH
<br />
<br />_~ iZ
<br />i~~
<br />l'~~~
<br />8~i==5
<br />.8ffiz
<br />o ~ 1\
<br />~8~
<br />
<br />M
<br />
<br />27(:1.
<br />
<br />
<br />280. PRONOUNC!;D DEAD IMa.. Day. Yej
<br />
<br />28d. PRONOUNCE:lJ DEAD (Houri
<br />
<br />P .M
<br />
<br />M__
<br />
<br />28e. On the basis. of examinahon and 'or investigation. in my opinIon death occurred' at
<br />the time. date and place and due 10 the c:ause(s) slated,
<br />
<br />IS. nature and Title} ..
<br />29, DID TOBACCO USE CONTRIBUT 0
<br />
<br />o YES IX] NO
<br />
<br />(Si nature and iillel ..
<br />30.' HAS ORGAN OR TISSUE DONATION BE!;N CONSIDER!;D?
<br />
<br />[j YES 0 NO
<br />
<br />30,b WAS CONSENT GRANTeD?
<br />DYES
<br />
<br />IX] NO
<br />
<br />31, NAM!; AND AODRESS OF CERTIFIER ,PHYSICIAN. CORONER'
<br />
<br />11yps or Print)
<br />
<br />Mehmet sitki
<br />
<br />
<br />M.D., 2116 W. Faidley Ave.,Grand Island, NE 68803
<br />
<br />32a. REGISTRAR
<br />
<br />32b. DATE FILED BY REGISTRAR IMo.. Day Yt./
<br />DEe 1 0 2004
<br />
<br />Lots Five (5) and Six (fl), Ross Heights Fourth Subdivision, in the City of Grand Island, Hall
<br />County, Nebraska
<br />
|