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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Lynn Louise Barta 2. SEX r Fertile 3. DATE OF DEATH (Mo., Day, Yr.) March 25, 2009 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Red Cloud, Nebraska 5a. AGE - Last Birthday (Yrs.) 65 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) August 9, 1943 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -54 -3059 8b. FACILITY -NAME (If not Institution, give street and number) 1149 North Nye 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient l2 Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Fremont 68025 8d. COUNTY OF DEATH Dodge 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Dodge 9c. CITY OR TOWN Fremont 9d. STREET AND NUMBER 1149 North Nye 9e. APT. NO. I 9f. ZIP CODE I 68025 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name James Barta 11. FATHER'S -NAME (First, Middle, Last, Suffix) Alfred McCall 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lucille Bauder 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME James Barta 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Jon Ludvigsen 16b. LICENSE NO. 1229 16c. DATE (Mo., Day, Yr.) March 31, 2009 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Barta Family Cemetery Linwood Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Ludvigsen Mortuary, 1249 E 23rd Street, Fremont, Nebraska 17b. Zip Code 68025 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 1S. PART I. Enter the chain of events- -diseases, injuries, or complicationsthat directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Immediate respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Unspecified Natural Causes disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) any, leading to the cause listed line on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE C ) (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO IF FEMALE: Not pregnant within past year El Pregnant at time of death Not pregnant, but pregnant within 42 days of death E l Not pregnant, but pregnant 43 days to 1 year before death ® Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by Attending PHYSICIAN ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) a § a c° k Y i a ti z W O ° W 2 O p ~ c) .8 124a. DATE SIGNED (Mo., Day, Yr.) March 31, 2009 24b. TIME OF DEATH Approx. 06:30 AM 23b. DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) March 25, 2009 24d. TIME PRONOUNCED DEAD 07:47 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 24e. On the basis of examination and/or investlg bon, In my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Paul Vaughan, Dodge County A torney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, ORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or P int) Paul Vaughan, Dodge County Attorney, 435 N Park Ave, PO Box 147, Fremont, Nebraska, 68025 28a. REGISTRAR'S SIGNATURE S Vpp�/V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I April 1, 2009 DATE OF ISSUANCE 04/06/2009 STATE OF NEBRASKA 201602924 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA„D.4PARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY.FOR L PFCQ�D CE1 COQPP'lf" •A,ASMSTANT STATE REGISTRAR0 DPI RTMENT OF HEALTH AND ,.;t LINCOLN, NEBRASKA FICIMAIP1ttIIVJCES - -c-- -""N STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVO E Imprinted Se al 09 0 1 192 CERTIFICATE OF DEATH {',' °fir