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<br />STATE OF NEBRASKA
<br />
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OFHEALI7:f.ANEJfWf;1AN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NE.B~~i{9firr.~~7i N7;OF...HE4,LTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FQ'If ~,QgO I "'I." ,
<br />~;.. ...... h'[ ,'" 0'0::,')/
<br />DATE OF ISSUANCE ( .;~.~ : .' . .,~
<br />
<br />, I,.(i. ._ .'
<br />, $t/JtNLEY S. COOPER '. C,' .....
<br />:; ~$IS~T-:sT~TE'iP.EGI5T:l?AR
<br />, , ()J?ARTMEfVT 6P1-fEAL THAlVD
<br />',' fltwVtAN SERVICES" .- '.....' .
<br />~~~~ ~ ~. f;~~/L.''''', ' ""~'.''''' .," ::,fAl"
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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES Flt.lANC~ SU"P ':'2 ....:':""
<br />CERTIFJ9AT~ OF DEATH ~ ~ '.~. .. "
<br />
<br />JUN 1 3 2008
<br />
<br />200805307
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />69
<br />
<br />L DECEDENT'S.NAME (FirSI, Middle,
<br />Lavern Louis Bunt ch
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Lasl,
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />
<br />Sa. AGE.Last Birthday
<br />(Yrs,)
<br />
<br />5b. UNDER 1 YEAR
<br />MOS, DAYS
<br />
<br />Male
<br />5C, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />3. DATE OF DEATH (Mo,. Day, Yr.)
<br />Jun,~-.!,_ 2008
<br />
<br />6. DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />Farwell, Nebraska
<br />
<br />68
<br />
<br />December 1, 1939
<br />
<br />Ba, PLACE OF DEATH
<br />
<br />llilS.fJ.IAL ;
<br />
<br />~ Inpatient
<br />
<br />QlliE8. 0 Nursing Home/LTC 0 Hospice FaCility
<br />
<br />FACILITY. NAME (II not inslitution, give streel and number)
<br />
<br />o ER/Oulpetlent
<br />
<br />o Deced.nt's Home
<br />
<br />Bt.. Francis Medical Center
<br />
<br />OCQi\
<br />
<br />o Other (SpecifyL
<br />
<br />Bc, CITY OR TOWN OF DEATH (Includ. Zip Cod.)
<br />
<br />Grand Island 68803
<br />ge. RESIDENCE.STATE
<br />
<br />90, COUNTY
<br />
<br />
<br />Bd, COUNTY OF DEATH
<br />Hall
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER 91. ZIP CODE
<br />
<br />19499 W Lou River Road 68820
<br />lOa, MARITAL STATUS AT TIME OF DEATH I Married 0 Never Married lOb, NAME DF SPOUSE (Fir.t, Mlddl.. L.st, Suffix) If wife, give maiden name.
<br />
<br />9g, INSIDE CITY LIMITS
<br />Q YES liD NO
<br />
<br />o Married. but separ.ted Q Widowed DDlvorc.d Cl Unknown
<br />
<br />Rosalee (NMI) Ewers
<br />
<br />1 L FATHER'S.NAME (First.
<br />
<br />Middle,
<br />
<br />Last.
<br />
<br />Suffix)
<br />
<br />
<br />(First,
<br />(NMI) Gei er
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />
<br />Louis (NMI) Bunt ch
<br />13. EVER IN U.S. ARMED FORCES? Giv. d.les of service if yes, 14a,INFORMANT.NAME
<br />(Yes, no, or unk,) No
<br />15, METHOD OF DISPOSITION
<br />
<br />.. Burial
<br />
<br />o Donation
<br />
<br />
<br />14b, RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />16c, DATE (Mo" D.y, Yr, )
<br />
<br />June 9 2008
<br />STATE
<br />
<br />o Cremation Cl Entombm.nt
<br />o Removal Cl Other (Sp.clfy)
<br />
<br />Paul, Nebraska
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City orTown, State)
<br />
<br />17b. Zip Code
<br />
<br />
<br />68803
<br />
<br />18. PART I, Ent.r th.llllaIll..Ill.~--dl...ses.lnluri.s, or complic.tions.-Ih.t dir.clly c.us.d Ihe death, DO NOT enler lerminalevents such.s c.rdiac arresl,
<br />respiralory .rresl, or ventricular fibrillalion wilhout showing Ihe etiology, DO NOT ABBREVIATE. Enter only one caus. on a Iin.. Add additional lines il nece..ary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE (Flnel
<br />d....... or cond~lon ,""ulllng
<br />In death)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(a) jil. JJ..f ,'.s
<br />
<br />DUE TO, OR AS AtONSEQUENCE OF:
<br />
<br />~tAJf:,h ~
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onsst to death
<br />
<br />Ilequenllaity liel condlllone, II
<br />.ny, leading to the coua. lIated
<br />on itnes.
<br />Enter tho UNDERLYING CAUSE
<br />(dl..aee or Injury th.llnltlat.d
<br />the events resulting In death)
<br />LASr
<br />
<br />(b)
<br />
<br />I5A d ~__ tArl G{r
<br />
<br />I onset to death
<br />I
<br />I
<br />
<br />" ____--L..-___,_~_~
<br />I on.etto death
<br />
<br />(c)
<br />DUE TO. OR AS A CONSEQUENCE OF;
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />1B, PART II, OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the dealh but nol r.sulllng In the underlying c.use glv.n in PART I,
<br />
<br />19. WAS MEDiCAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />DYES 0 NO
<br />
<br />20, IF FEMALE;
<br />o Not pregnant within past year
<br />o Pr.gnant.1 time of death
<br />o Not pregnant. but pregnant within 42 days of death
<br />o Not pregnant, but pregnant 43 days to 1 year before death
<br />o Unknown if pregnant within Ih. past ye.r
<br />
<br />2la, MANNER OF DEATH
<br />~alural Cl Homicid.
<br />
<br />o AccidBntO Pending Investigation
<br />
<br />21 b, IFTRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />o Drlver/Op.r.tor
<br />
<br />o P....n9.r
<br />
<br />Q YES
<br />
<br />J2lNO
<br />
<br />o Suicide Cl Could nol be determined
<br />
<br />o Ped.stri.n
<br />Cl Olher (Specify)
<br />
<br />2ld, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />Q.yJ;S .NO_
<br />
<br />Cl YES Cl NO
<br />
<br />
<br />m
<br />
<br />22a. DATE OF INJURY (Mo., D.y, Yr.)
<br />
<br />22b. TIME OF INJURY 22c, PLACE OF INJURY.At hom., farm, etreel, faclory, office building, construcllon aite, elc. (Specify)
<br />
<br />22d, INJURY AT WORK?
<br />
<br />221, LOCATION OF INJURY. STREET & NUMBER. APT, NO,
<br />
<br />CITYlfOWN
<br />
<br />Sf..:n:
<br />
<br />ZIP CODE
<br />
<br />--:1-- -~Eih(~------ ---
<br />jj~ ~_23a~~ATE~m~:~r~
<br />I~i 23b Dr;l r;Er~?Jy,Yr)
<br />
<br />u c
<br />.H
<br />i~!
<br />
<br />24.. DATE SIGNED (Mo., Day, Yr,j 24b. TIME OF DEATH
<br />
<br />
<br />"',..
<br />jj:!!:!i!!
<br />11!ll1l:
<br />tl~~
<br />D.a..iC~
<br />E -"t Z
<br />811::;:0
<br />1!~S
<br />~1I:(.l
<br />811
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., D.y, Yr.) 24<1. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e, On the basis of examination and/or investigation, in my opinion death occurred at
<br />Ih.lim., d.l. .nd pl.c. .nd due 10 the c.u..(s) .tat.d. (Slgn.lUr. and Till. ) 'I'
<br />
<br />25. DID TOBACCO USE CONTRIBUTETO THE DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />o YES 0 NO ')(PROBA8LY Cl YNKNOWN 0 ~ES ~O. ,."!,Ol Appllc.bl. if 26. is NO Cl YES NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Print)
<br />Travis Ha eman, M.D., 729 N Custer Ave., Grand Island, NE 68803
<br />
<br />28.. REGISTRAR'S SIGNATURE
<br />
<br />
<br />2Bb. DATE FILED BY REGISTRAR (Mo,. Day, Yr,)
<br />
<br />JUN 11 2008
<br />
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