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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HQMAN.SERVIGES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAtjRl;CO!iW_@~ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTIe5:SE(mofii;:WHfcH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. 'li~'-"">>:'''..,J i1~ --C\
<br />
<br />DATE DF ISSUANCE ftii!,,~R
<br />
<br />AUG 1 0 2006 20070384 8 AS~/ST~NrSTATERE.(ji~1lAR
<br />LINCOLN, NEBRASKA HEA'tTH ifNtlHl.!1!!AN-$ER'4CES
<br />
<br />- -
<br />..-
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORjh, rr::
<br />CERTIFICATE OF DEATH . Uo
<br />.,,, '.','. ------.,', - ' ,
<br />
<br />2'8S76,
<br />
<br />1. DECEDENT'S-NAME (Flrsl,
<br />Bruce
<br />
<br />Middle,
<br />Lee
<br />
<br />Last,
<br />Burnett
<br />
<br />Suffix)
<br />
<br />2.SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />July 27, 2006
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGE-Lasl Birthday
<br />(Yrs.)
<br />
<br />5b. UNDER I YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />e. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />April 23, 1929
<br />
<br />Grand Island, Nebraska
<br />
<br />77
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />506-26-8054
<br />
<br />ea. PLACE OF DEATH
<br />HQSfffAL;
<br />
<br />Xllnpalienl
<br />
<br />Q1lj@; 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />8b. FACILlTY.NAME (II nol tn.lttutt'"', give otteel.nd numbel)
<br />
<br />o ER/Outpallenl
<br />
<br />o Decode nt's Home
<br />
<br />St. Francis Medical Center
<br />
<br />OM
<br />
<br />o Olher (Specity)
<br />
<br />6c. CITY OR TOWN OF DEATH (Include Zip Coda)
<br />Grand Island
<br />
<br />68803
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />9a. RESIDENCE. STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1740 S. Blaine
<br />
<br />LOUNTY
<br />
<br />_ _!l<3.,l~_
<br />
<br />
<br />9g.INSIDE CITY LIMITS
<br />Xl YES 0 NO
<br />
<br />Island
<br />
<br />9UIP CODE
<br />68803
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH-'lliiM~;ried LJ Never Married 10b. NAME OF SPOUSE (Fir.t, Middlo, La.l, Sullix) II wite, glvo maiden name.
<br />
<br />o Married, but separated Q Widowed 0 Divorced 0 Unknown
<br />
<br />Jacqueline L. Menck
<br />It. FATHER'S'NAME--'f~s~ -- M~d:e, Bu;;~ t t Suffix) --j'-;~MOTHER'S-NAME F(:;~
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales of service 11 yes. 14a.INFORMANT.NAME
<br />(Yes,noJ~f):1/10/1951 1/8/1953 Jacqueline L. Burnett
<br />t5. METHOD OF DISPOSITION
<br />
<br />Middle, Maiden SlIrneme)
<br />Huegel
<br />
<br />14b. RELATIONSHIP TO DECED~NT
<br />
<br />Wife
<br />
<br />00 Burial
<br />
<br />I 6a. EMBALMER-SIGNATURE ~
<br />
<br />- ----~i;;~
<br />
<br />I 6d. CEMETERY, CREMATORY OTHER lOCATION
<br />
<br />STATE
<br />
<br />16b. LICENSE NO.
<br />-#
<br />_~!Lr
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />July 31, 2006
<br />
<br />o Donation
<br />
<br />o Cremation
<br />
<br />o Enlombment
<br />
<br />CITY /TOWN
<br />
<br />o Removal Q Other (Specify)
<br />
<br />Grand Island Cemetery,
<br />
<br />Grand Island, Nebraska
<br />
<br />
<br />17a. FUNERAl HOME NAME AND MAILING ADDRESS
<br />
<br />Apfel Funeral Horne,
<br />!
<br />
<br />18. PART I. Enter the c.haJ,rtP~--dlseases, Injuries, or complication sui hat directly caused the dealh. DO NOT enter lerminal events such as cardiac arrest,
<br />respIratory arrest, Or venltlcular fibrillation without showing the etiology, DO NOT ABBREVIATE, Enter only one cause on a line. Add additlonallinas if nacessary,
<br />
<br />I
<br />
<br />I onsst 10 daath
<br />I
<br />I
<br />...J__.
<br />I
<br />I
<br />I
<br />I
<br />
<br />iMMEDIATE CAUSE:
<br />
<br />(a) {~ ..l~~-l
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />r ~ t}
<br />'-u-~'-R
<br />J
<br />
<br />
<br />IMMEDIATE CAUSE (Final
<br />dls@3seorcondltlonresultlng
<br />in death)
<br />
<br />Sequentially 11.1 condlllons, 11 (b)
<br />any, leading 10 Ihe c.u..II.led DUE To';'(JR AS ACONSEQUENCE OF;
<br />on line a.
<br />Enlerthe UNDERLYING CAUSE
<br />(dl..... or Injury Ihellnlti.led (c)
<br />Iheeventsre.ulllng In death) DUE TO, OR AS A CONSEQUENCE OF;
<br />LASr
<br />
<br />onsello dealh
<br />
<br />onsello death
<br />
<br />(d)
<br />
<br />1 B. PART II. OTHER SIGNIFICANT CONDITIONS-Ccnditions conlrlbullng to the death bUI nol resullin9 in Ihe underlying causa givan in PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o YES
<br />
<br />o NO
<br />
<br />20. IF FEMAlE:
<br />U Not pregnant wllhin pa.t year
<br />o Pregnanl at time of death
<br />o Nol pregnant, but pregnant within 42 days of dealh
<br />o Nnt prognant, but pregnant 43 days 10 1 year belore dealh
<br />LJ Unknown II pregnanl wllhin Ihe paS! year
<br />
<br />21~~NEROFDEATH
<br />~Iural LJ Homicide
<br />
<br />o AccldentD Pending InvBstigation
<br />
<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Driver/Operator
<br />
<br />o YES
<br />
<br />y(NO
<br />
<br />Q Passenger
<br />o Pedestrian
<br />o Other (Specify)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />o Suiclde 0 Could not be determined
<br />
<br />J:l Y."-S_
<br />
<br />_.UNO
<br />
<br />22a. DATE OF INJURY (Mo., Day, Vr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY-AI home, farm, Slr.at, faclory, olllcB building, con.trucllon site, otc. (Spaclly)
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />U YES Q NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYrrOWN
<br />
<br />Sl1\TE
<br />
<br />ZIP CODE
<br />
<br />23a. DAT..E. OF DEATH (M. 0., Day,..y'I. .
<br />If/ )-1 0 G
<br />
<br />23b. DATE SIGNEP~1~ Day' Yr.) . 230. TIME OF DEATH
<br />cC /35Am
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />>~~
<br />.c~a:
<br />""'0
<br />n~
<br />c.a.. "1: ~
<br />E .",~ Z
<br />0'" 0
<br />"LJJ
<br />1JZ=>
<br />00
<br />~c::u
<br />o~
<br />uo
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and dUB to the cause(s) staled. (Signature and Title) ..,
<br />
<br />25. DID TOBACCO USE CONTRIBUTETOT
<br />
<br />6a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />
<br />o 0 PROBABLY 0 UNKNOWN 0 YES ".._____ No_I Applicable If 26a Is NO LJ YES o,];l'1LO
<br />27. NAME, TI E AND DDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR CO TV ATTORNEY) (Type or Prinl)
<br />Gordon J. Hrnicek M.D. 729 N. C ster, Grand Island, NE 68803
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />8 2006
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />AUG
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