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<br />__.IHIS Copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTflAtiQ:~7~ES""',."
<br />SYSTEM, IT CERTlFIES THE BELOW TO BE A mUE COpy OF THE ORIGINAL RfCOBIu:iii f1il.e:'NITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/~~~~:IS,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.'c:~~,.~~-:~\;!Jt;~'l__'S;"
<br />
<br />
<br />D~T;/O~';S/";;4 200509704 m~A
<br />"jSIStA#lr'$'t,A(1~'_ . . ,rMlt
<br />LINCOLN, NEBRASKA HEAL TH ANPHUMANif4 - '" --lttM '
<br />~~~ _ ::: ,:,~~_~ ~()ij:1l~,':':,~ ,~~ -"~-
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTII AND HUMAN SiRVT ' MPoRT
<br />VTTALSTATISTICS "",-.-',:'"\ ":o-;,,~r2-' =--
<br />CERTIFICATE OF DEATH ""=~~: ,; t~=-- -'~ 4
<br />
<br />1. DECEDENT" NAME
<br />
<br />FIRST
<br />
<br />MIOOLE
<br />
<br />LAST
<br />
<br />
<br />Geralyn
<br />.. CITY AND STATE OF BIRTH (/I 001 in USA" name Go"ntry)
<br />
<br />Bruns
<br />
<br />6, 2004
<br />
<br />Donna
<br />
<br />6. DATE OF BIRTH (Month. Day. Yearj
<br />
<br />UNDER' DAY
<br />5e. HOURS MINS.
<br />
<br />UNOER 1 YEAR
<br />5b, MOS. DAYS
<br />
<br />Sa. AGE - La" Binhday
<br />(Yrs.l 41
<br />
<br />23, 1963
<br />
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURTIY NUMBER
<br />
<br />ea. PLACE OF DEATH
<br />HOSPITAL: D Inpatient
<br />D ER Outpatient
<br />o DOA
<br />
<br />OTHE~: 00 NurSing Home
<br />
<br />D Reslden!::e
<br />CJ_~ Skilled Care
<br />~her ISVf!c/IVI
<br />
<br />505-64-0467
<br />
<br />eb. FACILITY. Name
<br />
<br />(If not institution, give stre8t ana ril,Jmb8r)
<br />
<br />Saint Francis Skilled Care Center
<br />
<br />8c. CITY TOWN OR LOCATION OF DEATH
<br />Grand Island
<br />
<br />
<br />8d INSIOE CITY LIMITS
<br />
<br />COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />9a, RESIDENCE - STATE
<br />
<br />
<br />13. NAME OF SF'OUSE Ilf wife. gllle maiden name)
<br />Bruns
<br />
<br />COUNTY
<br />
<br />90. STREET ANO NUMBER f/ncl"ding Zip Code)
<br />
<br />ge INSIOE CITY LIMITS
<br />
<br />Nebraska
<br />
<br />68803
<br />
<br />Ye. 00 No D
<br />
<br />10, RACE - le.g.. White. Black, Ameti!::a.n Indian,
<br />ele.IISpeelfy! Whi te
<br />
<br />11. ANCESTRY (B.g.. Italian. MeXIcan, Ge(man, etc)
<br />(Speelfyl American
<br />
<br />14a. USUAL OCCUPATION IGive kind of work done t;ll,ltlng most
<br />01 workmg life. even if retired)
<br />Treasurer
<br />
<br />Church
<br />
<br />16. FATHER - NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />
<br />James Bruns
<br />
<br />,AST
<br />
<br />17 MOTHER
<br />
<br />MAIDEN SURNAME
<br />
<br />Geraldine
<br />
<br />Schmidt
<br />
<br />Donald
<br />
<br />1 e. WAS DECEASED EVER IN U.S. ARMEO FORCES?
<br />(Yes, no, or unk.) 11f yes. give war and dales of services)
<br />No
<br />1 Sb. INFORMANT MAILING ADDRESS (STREET OR R,F.O. NO.. CITY OR TOWN, STATE. ZIP)
<br />
<br />3031 Idaho Ave., Grand Island, Nebraska
<br />
<br />21a. METHOD OF DISPOSITION 21b. DATE
<br />
<br />68803
<br />
<br />
<br />21c. CEMETERY OR CREMATORY NAME
<br />
<br />\
<br />(..,
<br />
<br />D Romoval Decenber 10, 2004 Grand Island ci t
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR roWN
<br />
<br />'1071
<br />
<br />
<br />[iJ Burial
<br />
<br />D Cremation D Don'''o" Grand Is1and,Nebraska
<br />
<br />All Faiths Funeral Home
<br />
<br />22b, FUNERAL HOME AOOAESS
<br />
<br />(STREET OR R.F,D, NO.. CITY OR TOWN. STATE, ZIP)
<br />
<br />2929 S. Locust st., Grand Islarid, Nebraska
<br />
<br />68801
<br />
<br />
<br />23. IMMEDIATE CAUSE P
<br />
<br />PART ..... .OJ <, ~,k,
<br />I lal VO V V;\ VI..;;..
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />
<br />~SE;~L1NElJ~t-
<br />
<br />C9...n.~-'
<br />
<br />---..
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEOUENCE OF;
<br />
<br />---
<br />
<br />(01
<br />PART O"rHE:A SIGNIFICANT CONDITIONS - Conditions con~ribLlting to the dEtatn but not related
<br />
<br />II
<br />
<br />
<br />28a.
<br />
<br />2Gb, OATE OF INJURY IMo.. Day, Yr.) 26e. HOUR OF INJURY
<br />
<br />o
<br />o
<br />o
<br />
<br />Accident 0 Unde1ermin$d
<br />SUicide 0 Pending
<br />
<br />260, INJURY AT WORK
<br />Yes 0 No D
<br />
<br />M
<br />26f. ~kfc~5u?t~i~~~~~Y -,t}:g~t farm. street, factory
<br />
<br />26g, LOCATION
<br />
<br />STREET OR R.F.D. NO,
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />HomiCIde
<br />
<br />Investigation
<br />
<br />27a. OATE OF DEATH (Ma.. Day. Yr,)
<br />
<br />2ea, OATE SIGNED (Mo.. Day. Yr I
<br />
<br />2Gb TIME OF DEATH
<br />
<br />~;;
<br />l~,"
<br />
<br />8 ~6
<br />.!l~
<br />o ffi
<br />~li
<br />
<br />December 6,
<br />27b.
<br />
<br />2004
<br />
<br />$~ ~
<br />h~~
<br />!~~~
<br />.!lWZ
<br />06 gOO
<br />~i5
<br />u"
<br />
<br />28e. On 1M ba~is of examination and'or investIgation, in my opinion death occurred at
<br />the lime, dale and place and due 10 the cauS9(S) stated
<br />
<br />M
<br />
<br />TIME OF DEATH
<br />
<br />28<. PRONOUNCED OEAD (MO, Day, Yr.)
<br />
<br />2M PRONOUNCED OEAD (HOUri
<br />
<br />29.
<br />
<br />
<br />30.b WAS CONSENT GRANTED'
<br />o YES IX] NO
<br />
<br />P ~M
<br />
<br />M
<br />
<br />27cl.
<br />
<br />DYES
<br />
<br />[j YES
<br />
<br />31, NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'
<br />
<br />IType or Prir'lf)
<br />
<br />Mehmet sitki Copur, M.D., 2116 W. Faidley Ave.,Grand Island, NE 68803
<br />
<br />32a. ~EGISTRAR
<br />
<br />
<br />32b. DATE FILED 6Y REGISTRAR IMo.. Day, Yr.)
<br />DEe 1 0 2004
<br />
<br />LOT 1, OSTERMEIER SUBDIVISION, HALL COUNTY, NEBRASKA.
<br />
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