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<br />~uu.tJ.UU"'U
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF DEATH
<br />
<br />3287'-"7('
<br />)
<br />
<br />~.-- "~-~..-------.... -~~-
<br />11. DECEDENT'S.NAME (Flr.l, Middle, Lasl,
<br />. Philip Clarence Bunkers
<br />- 4. CITV A~D STATE OR TERRITOR"V, OR FOREIGN COUNT~~ OF BI:JTH 5. AGE'L~~IBlrlhd.Y 5b, UNDER 1 VEAR 50. UNDER 1 DAV
<br />~ Colman, South Dakota (Vr..) . ,- MOS, DAVS HOURS MINS.
<br />........; 82
<br />.;;;;!I 7. SOCIAL SECURI~ . la. PLACE OF DEATH
<br />~ 503-18-6584 l:!.QJll'JIAl.: m InpoUonl
<br />-=== 8b. fACILITY. NAME (If nol Insmutlon, give stfEH;lt and numbst)
<br />o ERIoulpaUonl
<br />~
<br />- VA Medical Center 0 [0\
<br />-
<br />_ Bc, CITV OR TOWN OF DEATH (Includo Zip Coda)
<br />;BI
<br />
<br />Sulllx)
<br />
<br />2. SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo., Day, Vr.)
<br />~~cembe.r 5, 2Q_~
<br />B. DATE OF BIRTH (Mo" Day, Vr.)
<br />
<br />
<br />1925
<br />
<br />QlI:W
<br />
<br />o Nurolng HomeJLTC 0 Hosplca Facillly
<br />
<br />o Doeadanl'. Homa
<br />
<br />o Olh.r (Speclly)
<br />9d. COUNTV OF DEATH
<br />
<br />Omaha 68105
<br />"liidlElllbr;NCE.Sll\t!; lib. COUNTY Dc, CITY OR TOWN
<br />
<br />Nebraska Hall Grand Island
<br />~ 9d STREETANDNUMBER -. ~ ZIP CODE
<br />
<br />g ,".4~:,~, ~::'^;~.:; ~,~':,~n~:m~ 0 ,_, ..~ ",.."' ''''"'' "", "... ,"", ,",""" .., ,,~~~~..
<br />~ OM.~~paral.d O_WldOWOd_~DIVOrC9d .~~_~_. Madonna Barloon
<br />..::::::::iii 11. FATHER'S.NAME (Fir"" Middle, L..t, Suffix) 12. MOTHER'S.NAME (Flr.l,
<br />
<br />
<br />las
<br />
<br />eg. INSIDE CITY LIMITS
<br />~ VES 0 NO
<br />
<br />Mlddl.,
<br />
<br />Meld.n Surnamo)
<br />
<br />0IS01]__..
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />Al Bunkers
<br />.......--'" -.------,-'''."E----.
<br />~, 13. EVER IN U.S. ARMED FORCES? Glv. dale. 01., orvlce II yo.. Ua.INFORMANT.NAME
<br />_-= (Ves, nO,orunk.)Yes 6/26/44-5/29/46
<br />'-, . 15.METHODOFDISPOSITION 19a.EMBAL;",ER'SIGNAi-"lJRE...--t'~, ,'---' ..
<br />-==-t ,..---~ "
<br />- Q(aur'.1 0 Donation /"",r.,/ It- "".....,...::lo
<br />~ 0 Cremallon 0 Entombmenl 16d. cEMETERv, CREMATORV OR OTHER LOCATiON
<br />
<br />Siqne
<br />Madonna Bunkers
<br />~ENSENO. 1326
<br />
<br />CITV I TOWN
<br />
<br />19c. DATE (Mo., Day, Vr.)
<br />ecember 10,
<br />
<br />STATE
<br />
<br />20
<br />
<br />7
<br />
<br />o R.movo' 0 Othor (Sp.ctly)
<br />
<br />Westlawn Memorial Park Cemetery Grand Island, NE
<br />
<br />.oiiiiIiiii
<br />
<br />_~~",_~_......-------..r_'._
<br />
<br />
<br />iiiiiiii 170. FUNERAL HOME NAME AND MAILING ADDRESS (Slreal, Clly or Town, Stele)
<br />Apfel Funeral Home, 1123 West Second,
<br />
<br />
<br />lB. PART I. Enler the chain 01 avent'ndls.a.oe, Injurlos, or comptlc.llon,nth.' dl,aclly c.used Iha dooth. DO NOT onter t.rmln.1 ...nl. ouch .s cardiac err.sl,
<br />respiratory arrest, or vonUlcul.r IIbrlllaUon wllhout Showing the eUology. DO NOT ABBREVIATE. Ent.r only one caus. on ollna. Add .ddlllonalIIn..II n.c....ry.
<br />IMMEDIATE CAUSE:
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I
<br />I
<br />
<br />I on.et to d..,h
<br />I
<br />I
<br />I minutes
<br />
<br />I onset (0 death
<br />I
<br />I 2 days
<br />I
<br />, ons.\lO do.lh
<br />I
<br />
<br />.~days
<br />
<br />I onoo\lo doath
<br />,
<br />I
<br />
<br />IMMEDIATE CAUSE (Final
<br />dlseo,a or conellllo" rasulllng
<br />. iiideaih)
<br />
<br />(a) Cardiac Arrest
<br />-,'~-~
<br />DUE TO, OR AS A CONS~QllENCE OF:
<br />
<br />Soqu.nll.lly 1101 condlllon" II
<br />.ny, loading 10 the cau.. tlsled
<br />on line A.
<br />En....th. UNDERLYING CAUSE
<br />(dls.... or InJury IhallnlUol.d
<br />'h. ._10 ,""ulllng In daelh)
<br />\ASl"
<br />
<br />(b) Septic Shock
<br />
<br />(c) Intra-abdominal infection
<br />
<br />......------'--------,..----.---------
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />o VES [j: NO
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Condlllons conl,lbullng 10 Iho death bul not r.sulllng In Iha und.rlylng causa glvon In PART I.
<br />
<br />20. IF FEMALE: 21a. MANNER OF DEATI1 21 b.IF TRANSPORTATION INJURV 21c. WAS AN AUTOPSV PERFORMED?
<br />
<br />o Nol pr.gnsnl wllhln pasl y.ar IJ(Natural 0 Homicide ODrlverlOparalor
<br />
<br />o Pregnsnlat lima 01 de.th 0 AccldentO Pondlng Inv.,lIgellon 0 pa,.anger
<br />o P.de.lrlan
<br />o Nol prognanl, bul pr.gnanl wllhln 42 day. 01 de.lh 0 Sulcldo 0 Could nol b. delarmlnod 21d. WERE AUTOPSV FINDINGS AVAILABLE TO
<br />o Olher (Sp.cily)
<br />o Nol prognant, bul prognanl43 days 10 1 yoar belora da.lh COMPLETE CAUSE OF DEI\fH?
<br />
<br />o Unknown II prognenl wllhln the pasl ya., _._'" 0 VES 0 NO
<br />
<br />22a. DIiTEOFIN~:, Day, vr.~2b. TIME OF INJUR:' 22c. PLACE OF INj~;:I.rm, s"oe;, taclory, olii~"a bUlldln~, cons"ucUon slto, .Ic. (Speclly)
<br />
<br />
<br />2.2d.INJURV ATWORK:'..._1~20. D. E.~CRIBE "HOW IN.JURV OCCURRED
<br />o VES 0 NO
<br />~221. lOCA~ION OF IN~unv" STREET & NJMBER, AP;~~~.~ITYrrow~--
<br />
<br />o VES
<br />
<br />t1r NO
<br />
<br />.~~._-'.,...-------'-'--~~~
<br />
<br />SOOE
<br />
<br />ZIP CODE
<br />
<br />"
<br />
<br />z>-
<br />~a~
<br />i >- ~ 24c. PRONOUNCED DEAD (Mo., Day, VI.) :"'24d. TIME P~ONOUNCED DEAD
<br />l~~~ m
<br />
<br />B i5 ~ 0 240. On Ih. baa'e olexamlnaUon ondlo, Inveollg.Uon,ln my opinion d.alh occurred 01
<br />.8 ~ 8 Ih. lime, del. and plac. and due to Iha causo(o) .Ia'od, (Signature and TIUo) ...
<br />~I!;r.>
<br />j) 8 is
<br />
<br />25. DID TOBACCO USE CONTRIBUTElP"tIttJEATHt ,:' ... 26a. HAS ORGAN OR TISSUE DONIITION BEEN CONSIDERED?
<br />
<br />o VES 0 ~O r -\.f P~OB;BLV ri ~K'~dwN :w VES 1::1' NO
<br />2? NAME, TITLE AND ADDRESS OF CERTI~IE'R (PH IGIAN, CORONER'S PHVSICIAN OR COUNTV ATTORNEV) (Typo or Prlnl)
<br />Nathaniel M'B'it' 'e'nhe'ier~ M.D., VA Medical Center, 4101
<br />
<br />I!J.~~~
<br />
<br />24a.IJAI E SIGNED (Mo.. D.y, Vr.)
<br />
<br />24b. TIME OF DEAtH
<br />
<br />\
<br />
<br />m
<br />
<br />23c. TIME OF DEATH
<br />'.J \\ 2: 50 pm
<br />
<br />23d. To Ihe best d( my kn"1'la . go, lI118lh occuried .llho 11m., d.l. and place
<br />~nd d~i to Ihe o"..a(e) "lated. (SlgnOI:,r",nd:TIII.) ...
<br />
<br />....' .. ) .... e ~ .,'d '~ -
<br />
<br />
<br />2Gb, WAS CONSENT GRANTEO?
<br />
<br />Nol Appllcabl. If 29a 's NO 0 VE!l~._
<br />
<br />29.. REGISTRAR'S SIOrw:l)1;lE
<br />
<br />-"
<br />
<br />Woolworth Ave, Omaha, NE
<br />29b, DATE FILED BV REGISTRAR (Mo., Oay, Vr.)
<br />DEt 1 2 2007
<br />
<br />6810
<br />
<br />
<br />This certifies this document to be a true copy of an original record on file with Vital Statistics, Douglas County
<br />Health Dept., Omaha, Nebraska. Certified copies must have a raised seal in the area to the left. Reproductions
<br />of this green certificate are not legal copies,
<br />
<br />Date Issued:
<br />
<br />DEe 1 2 2001
<br />
<br />Registrar:
<br />
<br />AJl5- J~~
<br />
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