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WHEN THiS COPY CARRlES THE RAISED SEAL OF THE AtEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CFR�/F1ES THE BEtOW TO BE A TRUE COPY OF THE OR/G/NAt RECQI?9�FFJLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERV/CES SYSTEM, V/TAL STATISTIt�$E�110l�_ �ICH /S
<br />, THE LEOAL DEPOS/TORY FOR V/TAL RECORDS "
<br />, �
<br />DATE OF /SSUANCE
<br />� � ;�.�����
<br />12�� s�2oo4 2 0110 5 G 0� -�t � �
<br />. as�is����F�c�s�t�: ; ,
<br />L/NCOUY, MEBRASKA HEALTH AN�Itl�ib4N�S��.rES �Y$�'l1�; ' '
<br />. ��, .
<br />� � �° � r,� {,� � � �, : �
<br />STATE OF NEHRASKA- DEPAR4MENT OF HEALTFI AND HUMAN SERYI ��SE7p�$igfi v �
<br />V1TAL STATTSTICS =_ _'-'�'�
<br />CERTIFICATE OF DEATH ' - �� �, 3,_�
<br />1.� DECEDENT- NAME � FIRST �MIDDLE LAST 2 SEX 6A7E O� DEqTH° (Aqanfi. Day.. Yearj
<br />Geralyn Donna Bruns Female Decemb'�:i 6, 2004
<br />4. CITY AND STATE OF BIRTH ltlnot/n U.SA. name counby/ Sa AGE - last Birtl�day � UNDER 1 YEAR UNDER 1 DAY . B. � DATE OF BIRTH /MOr�tlt Day Yeer/ �
<br />(Yral Sb. MOS � DAYS Sc.HOURS' MINS.
<br />Grand Island, Nebraska 41 � October 23, 1963
<br />7. SOCIiAL SECURl7Y NUMBER . 8a �PLACE OF DEATH � � � � �
<br />HOSPRAL• InpatleM OTHER: Nurs�ng Home
<br />505-64-0467 - X�
<br />8b. FA II.11Y - Nama �(Unat inslXul/o2 glve street end number) � ER Outpatlent .� Reaidence
<br />Saint Erancis Ski lled Care Center �� ,� t118f ��,,�, S k i 11 e d C a r e
<br />8c. CITY. TOWN OR LOCA710N OF DEATH � . 8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH
<br />�Grand ISZSIIC� Yea � No � $�,�].
<br />�Ja RESIDENCE � STATE - . 5b. CAUNTY . � ' 9c. CITY. TOWN OR LOCATION - -- 9d. AND NUMBEq � /lnc/udingZtpCodel� � 9e INSIDE ClfY IJMITS
<br />NeYfraska Hall Grand Island 3031 Ic� A�... 68803 v� x❑ r,o ❑
<br />70. RAGE -(e.g., White. Black. AmeriCan UM(an. 71. ANCESTRY Ie.g,. Itallan, Mexican, �erman, atc� 12 � MAFiRIED ❑ WIDOWED 73. NAME OF SPOUSE pl wrle. give meiden nane�
<br />etc.�'�Speeify� W�1'te «�) American � NEVER , DIVORCED James Bruns �
<br />MARR
<br />14a US�UAL OCCUPATION /Give Idnd o1 wark done dwGig mvsf 74b. KIND OF BUSINESS INDUSTRY � 15. EDUCA710N (Specify onry highest grede completed�
<br />a/wnrkmglHe, even Hretlredl � demenlary or Secondery 10-12) It-4 or 5�1
<br />Treasurer Chnrch , 1 �Q
<br />16. FATHER-�NAME FIRST tdIDDLE LAST - 17 MOTHER FIRST MIDDLE MAIDENSURNAME
<br />Donald I,eiser Geraldiae � Schmidt.
<br />18. WA& DECE4SED EVER IN U.S. ARMED FORCES? 19a MFORMANT-NAME - .
<br />�(Yea ��no. or unkJ (It yes. give war and datas of aervicea�
<br />� �'a James Bruns
<br />_. ._...
<br />19b. INFORMANT MAILINfl ADDRESS ., �$TREET OR RED. NO., CITY OR TOWN. STATE. ZIP) � , .
<br />3031 Idaho Ave., Grand Islaad, Nebraska 68803
<br />20.. BALMER SIGN RE & UC NO. �' ._ � � � .. 27a METHOD OF DISPOSfTION 21b. DA'IE � � 21c. CEMETERY OR CREMATORY NAME -
<br />;� �/ , �� # 10 71 0�,,, � RQ „ m ��, � 10, 2004 Grat�d Tsland Cit Cemete
<br />NERAL HOME - AM 21 d. CEMETERV OR CREMATOfiV LOCA770N CITY OR TOWN -- STATE
<br />All Fai.ths Funeral Home ❑�� ❑o��� Grand Island Nebraska
<br />.�
<br />22b. FUNFRAL HOME ADDRESS - '(STREE7 OR R.F.D. NO_ CRY OR TOWN. STATE, ZIP� �� � �. ' .
<br />2929 S. Zocust St., Grand Island, Nebraska 68801
<br />23. IMMEDIATE CAUSE ' � � �ENT ONLY ONE CA� E PER LINE FO Ia1. (bI, AND (c�) � ,/� I� IMerve�l ° b 7 etween onset and death
<br />PARfaI 1� r'� g Y�� � V�� ����� �� W4�[ L' . ' V. �� `-" / C...�C..(�iY � I v �%I T_ '^' .
<br />DUE TO, OR AS A CONSEQUENCE OF � � I I�erval be�esn on�t and deam
<br />I
<br />_ --^"_'_ I .
<br />� � � � i . ___. .._
<br />.. DUE 70. OA AS A CORISEAUENCE�OF: � � �" � I �rrterval beRVeen onset antl death
<br />�,�,,,"^' I �� .
<br />fol - �
<br />i
<br />PA � OTHER SIGNIFlCANT CONDITIONS - Ca�ditlone conM6utlng to the death but Irot releteti PART III IF FEMALE. WA3 THERE A 24 AUTOPSY 25. WAS CASE REFERRED TQ MEDICAL
<br />. �� . . . � PREGNANCY IN THE PAST 3 MONTHS7 IXAMINER OR CORONEH9
<br />(Ages70-54�� Yes No Yea No x Yes No g
<br />28a 26b. DATE OF INJURY /MO_ Day. Yr.J � 28c. HOUR OF IWURY 28d DESCPoBE HOW INJURY OCCU ED .
<br />� AcddeM � Ur�delermined � . . �
<br />M
<br />❑ Swdde � PenNng 26e. 1NJURY AT WORK ' 26t PLAC�F�� � 1grm, yyreet fflctory 28g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />offlc n}•
<br />❑ Homicide In�esd9�^ Yas � No � . . .. � .
<br />. 27a DATE OF DEATH ' /Ma Oay. Yt) �- � � 28a �ATE SIGNED (Ma Day. Yr.1 28b TIME OF DEATH
<br />December 6,`2004
<br />s
<br />M
<br />=��� J. 27b. DATE SIGNEII- (h�a. Day. Yc) 27c. TIME OF DEATH -- ��� k 2ga PRONOUNCED OFAD (Ma Dey, Yr.l 28d PRONOUNCED DEAO (Hourl
<br />(q a Z
<br />� a�- ' 1I:3O P.M � M
<br />_�� ���
<br />+ 27d To the bast of my owiedge. tl atFt ffi tl�a tlme, daze arM piace and due to tlre . �? s '�e. On itte basis nf examinaHOn arW �or investlgation, in my opinion deeth occurtatl at
<br />- causelsl steted. � f c � the 6m& date and place artd due ro the causefs! atate0.
<br />lS�gneture arW Tklel ► j \
<br />. � �Si az�d Tltte) ► .
<br />-- 29. DID TOBACCO USE CONTHIB O DEA ?, 30.a AS OROAN OR TISSUE DONATION BEEN CONSIDERED? � 30b WAS CONSENT GRANTED?
<br />� YES � NO � UNKNOWN � YES � NO �� YES � NO
<br />31. NAME AND ADDflESS OF CEPTIFIER (PHYSICUUV, CORONEF1' PHYSICIAN�OR COUNTY ATTORNEYI� flypeorPdntl . �
<br />Mehmet Sitki Copur, M.D., 2116 W. Faidley Ave.,Grand Island, NE 68803
<br />32a. RE6ISTRAR �
<br />l 32b. DATE FlLED BY qE61STRAR /Mo_ pay. Yr./
<br />!I. �EC � 0 20��
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