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<br />STATE OF NEBRASKA
<br />T,�_ .
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<br />WHEN THIS COPY CARRIES �HE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL.�h/ AN�;N��'1AIV SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF TH�' Of27GINAL RECORD ON FILE WITH THE NEBRA`SKA"��`��'AR.T.lt1L�1T..4F,HEALTH AND
<br />HUMAN SERVICES, VITAL REC()RDS �FFICE WHICH IS THE LEGAL DEPOSITORY FOR V�A� ��'� �•,�,
<br />pATE pF I$SUANC�' . 'r�:►'" .
<br />�
<br />��� 2 9 2009 2 010 0 7 9 8 4 aS,SISTAl4� ���5T�AR ✓`
<br />DEP,�RTMENT Q� KE�ILTM AI,�D
<br />LINCOLN, NEBRASKA HUMAIV'S�,!/IC'�S .,,x'i�•,•' "
<br />�. � , ,°� � �.. ,
<br />� STATE OF NEBRASKA - D�pARTM�NT OF H�ALTW AND HUMAN SERVIOE�S ` .i � ', �4� � ' �,,� � p'. /�
<br />�� �F
<br />7. oEC6oENTS-NAML (1=1ni, Middle, Leat, SufNx) 2. SEX � .DATE UF DEATM (Mo:;��y,Yr.)
<br />�Vemon Albert Bruns Male September 8, 2009
<br />4. CITy AN� $TATE OR TERRITQRY, OR FbREIGN COLIN7RY OF BIRTH 68. A6E-L9�t BlRhdey li6. UN�ER 7 YEAR 6c. UN�ER 1 DAY 8. DATE OF BIRTH (Ma„ ppy, Yr.)
<br />(Yra.) MOS. W1Y8 MOURS MINB.
<br />Merrick Caunty, Nebraska 77 �ecember 20, 1931
<br />1. $pC1AL $ECU1tITY NUMBER Be. PLACE OF DEATH
<br />� 508�48-8703 HOSPITAL: � InprtlrM OSHER; � Nuning HomeILTC � Hoaplc� Faclllty
<br />�
<br />� 84. FACII.iTY-NAME (If not Inatltutlon, glve alraat and num6v) . .. � ER/Oulpatlen! �] ��cedenCa Hqma
<br />� � � DOA � Olher�3p�clfy)
<br />o Veterans Affairs Medical Center
<br />-� Bc. C17Y OR TOWN OF CEA?H (InCluda Tip Cod�) ed. COl1NTY Op GEATH
<br />g
<br />u � Grand Island 68803 Hall
<br />= 9e. RESIDENCE-STATE 9d. COUNTY 9c. CITY OR TOWN �
<br />7
<br />LL
<br />�, Nebraska Hall Grand Island
<br />� Bd. STREE7�ANU NUMe�R 9e. APT. NO. 9�. Zlp COUE By. IN91�E CITY LIMIT$
<br />m
<br />= 2715 O'Flannigan 68803 � ve� ❑ No
<br />� 10A. MARITAL STATUS AT TIME OF UEA7H � M�rr1�d ❑ N�wr Marrlad 706. NAME OF $POUSE (Flnl, Mlddla, Last, Sulllx) If wife, piw malden name.
<br />❑ Marrlad, buR aaperetad ❑ Wldowsd ❑ plvarced . Q Unknown Delares Thomsen
<br />a 71. FATHER'8-NAME (Flral, Mlddle, L�at, Suffix) 12. MOTHER'9-NAME (Flrat, Mlddl�, Mildan $umame)
<br />�
<br />O
<br />� Albert Bruns Anna Kaiser
<br />� 146. RELATiqN$Hlp TO pEGEpENT
<br />(A 13. EVER IN U.S. ARM�I7 FORCES? G�vs datas af �arvlea if Yra. 14a. INFORMANT-NAME
<br />O
<br />�- �r.s, No, o.u�k.� y� 11/20/1952-10/2 /1954 elores uns Wife
<br />16. METHOU OF OI$P091TIpN 1Ba. LMEit-$10 ll � • 18b. LICEN$E NO. 78c, �ATE (Mo„ �ay, Y�.)
<br />� p � � � 7� Se tember 11, 2009
<br />�Gnm�elon �Entam6m�m
<br />�e�movai �otn.qepecny� 78d.CEMETERY,CREMATORYOR �HERLOCpT10N GIIYITOWN STqTE
<br />Zion Lutheran Cemetery Worms Nebreska
<br />77a. FUNERAL HOME NqME ANp MAIIING AUORESS (Sfrssf, Clly o� Town, Slste) 77b. Zlp Coda
<br />All Faiths Funeral Mome, 2929 S. ��ocust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH (See instructions and exam les
<br />1i. PAR7 i. Enter Uw y�.�y�pte �- dwu�s, �n}um�, ar comW�c�nan�- tn�t eincuy c�uwa m� w�tn. oo Noi �m�r t�rmmai �wnt� �ueh a� earduc .m�4 � APPROXIMATE INTERVAL
<br />ro�pintory �rm6 or wneAeulu tlbdll�tlon wltnout �now�np tha e�lalapy. C�0 NQT A98REVMTE. En1x onry one c�uw en a nn�. Aatl auanion�l Ilms M n�cnary. �
<br />IMMEDWTE CAUSE: ' on�at tn de�th
<br />�
<br />IMMEDIATE CAl1SE (Final � �
<br />diseasearcondie�onroeult�ng s) ���U1�2d neumonia �
<br />m a..m� P P
<br />�11E Tp, qR A$ A CONSEQl1ENCE OF: � Ohas! lo dlsth
<br />i
<br />Saquantlpllyllelaandlllona, b� metastatic 11011�SIIlR��. CE�.1 LLill. CS1.1C@Y' i
<br />eny laedlnq to the a�u�e Iiatad g
<br />on Iina a. pue r0, pR a8 p CONSE4ueNCE OP: � onaet lo dsath
<br />EnterthaUNDERLYINGCAUSE �) metastatic disease CO �rlfl liver �
<br />(dl��aa� orinJurythatlnitlat�d �
<br />tM �vanh nsulling In daath) DpE TO, OR A9 A CONSEQUENCE OF: � onsNlo daath
<br />LAST �
<br />d� anoxexi.a leading to cachexia �
<br />18. PART II.OTHER SIGNIFICAN7 CONnITION5-Canditiona contrlbuting to tha death but not resulting �n the undaAying csuae glvsn In ppRT 1. 19. WAS MEDICAL EXAMINER
<br />OR CORONER CpNTACTE�7
<br />Q YES � NO
<br />0.'
<br />W 70, IF FEMA4E: 47a. MANNEIt OF OEATH 71b. IF TRANSPORTATION INJURY 27c. WA8 AN AUTOPSY PERFORM6D?
<br />ti
<br />N ❑ Not prepnent with�n pa�t year � Netural ❑ Homicide ❑ Ddv�dpp�rator ❑ YES �NO
<br />y�j ❑ Prepnant rt time at dr�th ❑ Accldrnt Q Pendlnp Invartlgation ❑ Pusenger y1d, WERE AUTOPSY FINDINGS AYAILABLE
<br />V Q Noe pngnan4 but proqnent withln 47 daye oT death ❑ Sulclde [] Gould not. be detsrmined ❑ PedastHan TO COMPLETE CAUS! OF OEATH7
<br />�7' ❑ Nol propnant, but prepnan! 43 deys to 1 qeur heToro deslb ❑ Other (Speeiry) ❑ YES ❑ NO
<br />� QUnknown I/ pngnsn! wlthin th� past yesr
<br />�
<br />a
<br />� YRs, nA7E OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 27c. PLACE OF INJIIRY-At hormr, tnrm, �treat, Tectory, otflce bui�dinp, construction dte, etc. (Sprciry)
<br />U m
<br />m 22d.INJURY AT WORK7 22e. OESCRIBE HOW INJURY OCCURRED
<br />H
<br />❑ YES [�NO
<br />22L LOCA?ION tlF INJURY - 97RHET 6 NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />. 4Sa, �ATE OF �FATH (Mo., �sy, Yp) Z � �4n, ppTE 316NEU (Mo., D�y, Yr.) 246. TIME OF DEATH
<br />�w 5eptember 8, 2009 �.�� m
<br />�� 23b. DATE SIGNEO (Mo., pey, Yr.) 13c. TIME OF UEATH �}� 24c. PRONOl1NCE0 DFAO (Mo., Day, Yr.) 24d. TIME PRONOUNCEp pEpp
<br />o�o �• ��- l�q 1602 p m o�a o m
<br />m � 23d. To tha 6ast oT my knowladge, death occurretl Bt tha tlme, d�t� and place � W �i SAl. OO Qle bApla p� /XAl11IOAH011 AIIfIIOP II1V06[IQLHOfl� in Illy Opirlloh d�ath opcumd
<br />� p and due to the ceuee(a) statad. (Siqnaturo and Title) � 7 at the time, data and placa and dua to the csuaa(a) epted. (Slpnetura end Tltle)
<br />r� � _ � „KJ F � o
<br />26. �IU TtlBACCb U$E CqNTRIBUTE TO THE DEATHT 26a. HA5 OROAN OR TISSUE OONATION 9EEN CON$I�EREp7 YBb. WAS CONSENT GRANTE�?
<br />Q YES � NO ❑ PROBABLV ❑ UNKNOWN ❑ YES � NO Nof Applica6la fl SBa Is N� [] YES ❑ NO
<br />27. NAME, 71TLE ANp A�DRR88 OF CERTiFIER (PHY6�CIAN, PHVSIGIAN ASSISTANT, CORONER'8 PHYSICIAN OR COUNTY ATTORNEY) (Type or Pdat)
<br />Heidi Beckett M.D. VA Medical Center 2201 IV Broadwell Grand Island, NE 68803
<br />28+. RE6ISTRAR'S SIGNATURE 28h. bATE FILED HY REpI$TRAR (Mo., 4ay, Yr.)
<br />P s EP 2 4 2p09
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