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STATE OF NEBRASKA # ��
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<br />W�fEN '�HIS CUPY CARRIES THE RAISED S�pL OF T`HE NE�RASKA DEPARTML�'{ItT'� �Y�Q7i�-1"���JUMANSERVICES, IT CERTIFIES
<br />THE ¢ ELOW TO QE A TRUE COPY OF THE ORIGIN�IL RECORD ON FILE WITMM-TFl���B _,�i411��R`��'1�111T OF HEALTH AND
<br />HUMkN SERVICES, VITAL RECORDS OFF3'CE, WHICH'IS THE LEGAL DEPO,�1T(�Y• ��FA�I�A�j �,
<br />, � �
<br />DATE t7F ISSUANCE ,���'" I r „'
<br />� I J f°" �,4�"i O I ft1 b������
<br />F A r�c : ��lVL � SE QOPEi4 ..e '
<br />�CT,� 8 �009� � '=� `� � s .A�1'�7`�TA�'�EC�I5TRAR
<br />� � � � ' "�t ��.d ��?�4R�'J�d �OF�IF.�tCTH,�AND
<br />flNCOLN, NEBRASKA � � tIFC �_
<br />� 2�01���200722 `�����.�..��"��� ,�� � � _
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<br />� 4 � e :� � w �� �:$ ��-. � . . . . '
<br />STATE OF NEBRA3KA'- DEPARTMENT OF HEALTH AND HUMAN 3ERVICES FINANCEAND�l1PP0 '
<br />CERTIFICATE OF DEATH � �, �;� � � $ --.
<br />�'�� 1.DECEDENTB•NAME (Firet, Midd�e, Lsat, BuHix) 2.SEX 3.DATEOFDEATH(Mo�,-Day,Yr.)
<br />��� Joel Oliver Bardwell Male September 29, 2009
<br />u � . �;;
<br />°,'��"` 4. CITY AND STATE ORTERRITOqY, OR FOREION COUNTRY OF BIRTM Sa. AOE•Laet Blrthtle 6h. UNDER 1 YEAR 5G• UNDER 1 DAY 8. DATE OF BIRTH Mo., Ue Yr.
<br />����:�' � Y , � Y. )
<br />f (Yre.) MOS. DAYS HOURB MINB.
<br />w3 ,., Fairbax�ks, Alaska 72 August 7, 1937
<br />;�
<br />:��,`�''; 7.SOCUU.SECURITYNUMBER BaPLACEOFDEATH ,
<br />�,'� 5��1-10-8325 - "' NOSPITAL• O InDeQerA 4ffi� ❑ Nwsi�HomalLTC ❑HasPiceFacNty
<br />a�'f�
<br />`;! ��� 6b. FACIUTY•NAb1E pf hol inetitution, giye etreet end number) ����e�U O DecedenfeHome
<br />;` { St. Francia Med3cal Cettter v � �����
<br />���� 4 �� 8c. C�TY ORTOWN OF DEATH (Include Zip Ccde) � � � Bd. COUN7Y OF DEATH �
<br />`'�^ Grand Island 68803 Hall
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<br />;:;, ee ncc�ncnirto_merc � . - rn. min�rtv � m. nnvnoTrnuni
<br />Nebraska Ha11 Grand Island
<br />8d8TREETANDNUMBER 9e.APT.NO„ Bf.21PCODE Bg.INSIDECITYLIMIT9
<br />31�2 Brentwood Circl�e 68801 �i res ❑ No
<br />10a MARITAL 8TATUS AT �'IME OP DEATH �J Married O Never Manied 106. NAME OF BPOUSE (Firat, Middle, Laet, SufPoc) If plfe, give malden neme.
<br />❑ Ma��ea, wf eepera�ea O r�mo.rea D nn�o�c�d o uA�nown Wgtida Iiof richter
<br />i
<br />11. FATHER'&-NAmE tFiret, Middle, Laet, Sufflx) 12. MOTHER'S•NAME (Flrst, ' Middle, Maidan &urname)
<br />Louis ' Bardwell Beulah Gault
<br />13.EVER�NU.B.AAMEDFOflCEB?aheda�esofservlcetfyas. 14aINFOqMANTNAME ' � � 14b.RELATIONBHIPTOUECEOENT
<br />�vae;�o,or���.�' No Wanda Bardwell Wife
<br />18. d1ETHOD OF DI3POSITION 18a EMBALMER-SI(iNATURE 18b. LICENSE N0. 18c. DATE (Mo., Day, Yr. )
<br />o�,�� 000�uo� Not Embalmed -- ' October 1, 2009
<br />�CremeBon OEMOmbmera 18d•CEMETERY,CREMATORYOROTHERLOCATION CITY/TOWN STATE
<br />❑a�o� vanB��s„�ny� Westlawn Memorial Park Crematory • Graad Island, NE .
<br />�
<br />17aFUNERALHOMENAMEANbMAILIN(iADDRESS (SVeet.CityurTo�a,State) 17b.ZtpCode
<br />Aufe1 Funeral Home 1123 West Second, ,Grand Island, NE 68801
<br />1& PART I. Enter the chaln of eventa-�dfaeasas, InJurlea, or complicadena-that tlireetly eaused tha death. DO NOT enter ferminel events auah ae cardiac arteat, � �'��TE ��'�T��
<br />I
<br />respUet�y azrea4 � Yentr�eWarBbtitledun ailAout ehowMg the e�ulogy. DO NOT ABBREVIATE. Enter only ane ceuee on e Iine. Add addidonal Ifnes H necessery. �
<br />iMME01ATECAUSE: i Orreelludeath
<br />,,,�,���, �e� card�opulmonary arrest ; 30 minutes
<br />�m�°^��8 �UETO,ORASACON3EOUENCEOF. I onaetlodeaN
<br />Mde�h) i
<br />,s��n���,� ro� fractured arm, leg and pelvis ; 45 minutes
<br />�'�� OUETO,ORASACONSE�UENCEOF: � onaetrodeath
<br />on qire e. ' i
<br />EMertlmUNDEHLYPItiCAUSE
<br />��a�o��r� ��� fall ; 45 minutes
<br />�������� OUETO,ORASACONSE�UENCEOF„ � i onaettodeath
<br />IAS� I
<br />1� �
<br />� 18. PART I I.OTHER SIONIFICAN7' CONDITIONS•Coml�tlons contrlbuUng to the de�N Cut not rasuRing in the undertying cfluse gfven In PART L �� � � 18. YdAS MEDICAL EXAMINER
<br />. - � � � . OR CAAONER CONTACTEDI
<br />� � � ��. ❑ YES � NO
<br />ZQ.IFFEMALE: 21a.idANNEROFDLATH 27b.IFTRANSPORTATIONINJURY 21aWASANAUTOPSYPERFORMEO?
<br />O Notpregnantwithlnpes[year ❑Nalural ❑Homtclde ❑OrlvedOperetor
<br />❑ Pregnantatdmeotdeath fj�AocldentOPemiinglmestlgatlon �P�n88� � YES � NO
<br />O Notpreqnent.butpregnantwithin42daysofdeeth � � 21d.WEREAIJTOPBYFINDINOSAVAILABLETO
<br />Oswaae ❑Couldrrothadetertnined ❑�;er(svacnyl.
<br />�v Nm Weenem, awP�e�an�aaaaysro � yaarcaroredeem con�a�recausEOFO�
<br />❑Unknoamilpregnentwilhlnthepastyear ❑YES J�]NO
<br />22a.0ATE OF INJURY (Ma., Dey, Yc) 22b. TIME OF INJURY 22c: PLACE OF INJURWAt home, term, etreet, taCtory, offisce buiiding, conetrucdon sfte, etc. (Specly)
<br />5eptember 29, 2009 2:15 pm home
<br />2ZdINJURYATWORK? 22e.DESCRIBEHOWINJUHYOCCUFlAED
<br />� Q YES �NO .f .� r m tree
<br />22LLOCATIOIVOFINJURY-STREET&NUMBER,APT.NO. CITYlfOWN BfAE ZIPCODE
<br />3112 Brentwood Circle Grand Island NE 68801
<br />P3a.DATEOFDEATH (Mo.,Day,Yr.) 24a.DATESIQNED (Ma,Day,YrJ - 246.TIbIEOFDEATH �
<br />� -_ �_� 23b. DATE SI�NED (Mo.. Dfly, Yr.)
<br />��� �
<br />� 23d.To the best ot my krmwiedAe. t
<br />� ;�,;' �� end tlue to the ceuse(e) state�
<br />� �;� , � �,
<br />�� zs.niqroenoc0usecon�rAisureront
<br />�� � � � ❑ YES $I NO ❑ PFiOBABLY,
<br />27.NAME,TITLEANDAODRESSOFCERTIFl
<br />��,Lynelle D. Homolka,
<br />� * � �26aREGISTRAWSSIQNATURE ��
<br />i � ��� � � : . � ��,
<br />.�� � ber 14� ZU 1603 "'
<br />� 23C.TIME OF DEATFi � � 24c. PRONWNCED DEAD Ma, Yr.) 24d. PRONOUNCED DEAD
<br />m ��, s� Sept mber 2�9,� 0 1��3 m
<br />�ath occurred at the dme, date end pteCe � � 24e. n th es o1 examl � on aiM/o gatlon, in my opinion death axurted at
<br />(Slgnature and 1Ttie )♦ '�, o�� e aml ue o cauee(s) ed. (3lgneture end ntle )♦
<br />r�� uty Hal l Coi
<br />OFATH? 28a. HAS OROAN OR TI$BUE DONATION N CO DERED7 28b. W S GONSENT �RANTEO?
<br />O UNKNOWN ❑ V5S CXNO NotAppllcable1t28a1eN0 ❑ YE3 ❑ NO
<br />ER (PHYSICIAN,CORONER'SPHY3ICIANORCOUNTYATTpRNEY) (fypeorPrintj
<br />Deputy Na11 County Attorney, 231 S. Lpcust St., Grand Island,
<br />�� � � � 28b: �ATE FlLED BY RE�I9TRAR (Mo., Dflg Yc)
<br />d, Ol, 1 1 O ZUUJ
<br />HHS-67 11103 (55D61)
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