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<br /> STATE OF NEBRASKA
<br />
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAUTt-4jd yUA'AN'6;E VICES;, IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH '"HE NEEaASI~~1 O~;f~EALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITQRY FOP,7.I
<br /> DATE OF ISSUANCE 201001584
<br /> ~,T WLEY R__C gPER ~A
<br /> 01/12/2010 A$ArsTAN S A
<br /> ARE ISTR4~t'
<br /> p,O*T', t NT OF #f aLrf AAP
<br /> LINCOLN, NEBRASKA HfJMf~I SICES ,
<br /> STATE: OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERA E ~~y~~{ Y.
<br /> "
<br /> ~'r~~; 10 00038
<br /> CERTIFICATE OF DEATH 7
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX 'DATE OF DEW H (Mo., Day, Yr.)
<br /> Barbara Jean Brunt Female Ji6U'ary6, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last airthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> IY►a.l MOS. DAYS WpURS 'MINE.
<br /> Coffey, Missouri 75 December 31, 1934
<br /> 7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH
<br /> 507-36-9926 HOSPITAL ® Inpatient OTHER © Nursing Home/LTC Hospice Facility
<br /> Bb. FACILITY-NAME (if not Institution, give street and number) ❑ ER/Outpationt ❑ Decedent's Home
<br /> Nebraska Heart Hospital ❑ OOA ❑ Other (specify)
<br /> Lu Sc. CITY OR TOWN OF DEATH (include Zip Code) 8d. COUNTY OF DEATH
<br /> o Lincoln 68526 Lancaster
<br /> 8a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br /> z Nebraska Hall Grand Island
<br /> D 9d. STREET AND NUMBER e. APT, NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> LL.
<br /> 408 N. Cherokee Ave. 68803 ® YES ❑ No
<br /> a 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSIE (First, Middle, Last, Suffix) If wife, give maiden name
<br /> !i= ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Lealand Dale Brunt
<br /> 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12, MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Irvin Coons Maxine Ungles
<br /> 13. EVER IN U.S. ARMED FORCES? Give dates of service If f. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> E
<br /> (Yes, No, or Unk.) No Leland Dale Brunt Husband
<br /> 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO, 16c. DATE (Mo., Day, Yr.)
<br /> ® Burial ❑ Donation Michael B. Williams 1083 January 11, 2010
<br /> ❑ Cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br /> © Removal ❑ Other (Specify)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zlp Code
<br /> Livin stun-Sondermann Funeral Home 601 N. Webb Road Grand Island Nebraska 68803
<br /> ea Instructions an examples)
<br /> 18. PART I. Enter the chain of events--diseases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL,
<br /> respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add additional line If necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Cerebral Vascular Accident ; 24 Hours
<br /> disease or condition resulting
<br /> in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br /> Sequentially list conditions, If b) Myocardial Infarction E Days
<br /> any, leading to the cause listed
<br /> on line a.
<br /> DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE G)
<br /> (disease or Injury that Initiated
<br /> the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ~ onset to death
<br /> LAST d)
<br /> 18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART 1. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> W [I YES ® NO
<br /> W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ~ ® Not pregnant within past year ® Natural © Homicide 0 Driver/Operator ~ YES ® NO
<br /> v ❑ Pregnant at time of death ❑ Accident © Pending Investigation ❑ Passenger
<br /> Not pregnant, but pregnant within 47 days of death © Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> ,p ❑ Not pregnant, but pregnant 43 days to 1 year before death Suicide Could not be determined Other (Spaciq)
<br /> © TO COMPLETE CAUSE OF DEATH?
<br /> ❑ Unknown if pregnant within the past year ❑ YES ❑ NO
<br /> g 22a. DATE OF INJURY (Mo., Day, Yr.) 22 b. TIME OF INJURY 22c, PLACE OF INJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br /> ,p 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br /> 0
<br /> ~ ❑ YES ❑ NO
<br /> 22f, LOCATION OF INJURY • STREET & NUMBER, APTAO, CITYlrOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OR DEATH
<br /> January 6, 2010 '
<br /> 23b. DATE SIGNED (Mo,, Day, Yr.) 23c, TIME OF DEATH 24c. PRONOUNCED DEAD (Mo,, Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> Janus 8, 2010 05:20 PM i
<br /> 6 3d. To the beat of my knowledge, death occurred at the time, date and plats 24e. On the in of examination and/or Investigation, In my opinion death occurred at
<br /> and due to the cause(s) stated. (Signature and Title) 813 the lima, data and place and due to the cause(s) stated. (Signature and Title)
<br /> s Denes Korpas, MD N
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN ❑ YES ®NO Not Applicable If 262 Is NO ❑ YES NO
<br /> 27. NAME, TITLE XNM L!11125~ OF CERTIFIER (PHYSICIAN, PH
<br /> YSjclAN ASSISTANT, CLIKONER'S PHYSICIAN UK COUNTY ATTORNF;Y) (Type or Print)
<br /> Denes Korpas, MD, 7440 S 91st St, Lincoln, Nebraska, 68526
<br /> 28a. REGISTRAR'S SIGNATURE ~f, J I R , 287 DATE FILED 13Y REGISTRAR (Mo., Day, Yr.)
<br /> January 11, 2010
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