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STATE OF NEBRASKA Skirt gK 0 cc t W 2 0 I -- re U 1. DECEDENTS - NAME (First, Middle, Last, Suffix) B Ce A Barth 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday (Yrs.) Comstock, Nebraska 7. SOCIAL SECURITY NUMBER 508-40-4011 b. FACILITY-NAME (If not Institution, give street and number) Bryan Medical Center East 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68506 9a RESIDENCE -STATE Nebraska 9d. STREET AND?NUMBER 1907 Stolley Park Circle Oa. MARITAL STATUS AT TIME OF DEATH Married, butseparatett ❑ Widowed 1. FATHER'S -NAME (First, Middle, Last, Suffix) Adolph Bartu 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit,) No 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NA ME ° AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska IMMEDIATE CAUSE (Final . .....axe or conrnt,nn resurino equentially hat collditions,:if any, tedding to the Causa listed on line a. Enter the UNDERLYING CAUSE (disease ortnjurY that inttlared the events resulting in death) LAST:: iK 20. IF FEMA ❑ Not pregnant Within past' year ❑ Pregnant at time of death ❑ Not pregnant. but pregnant within 42 days of death .sa ro L7 Not pregnant, but pregnant 43 days to 1 year before death ❑ unknown if pregnant within the past year l:L E O V 22a. DATE OF INJURY (Mo., Day, Yr.) WHEN THIS > COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 11/22/2016 LINCOLN NEBRASKA 2i. i3 rci:i aF: Gt l: •❑vco ❑NQ .rA r_ rr ((Vv., Ca., Novem.bet:6 2016 28a. REGISTRAR'S SIGNATURE STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 9b. COUNTY Hall 16a. EMBALMER-SIGNATURE Laurie D. Sheffield DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22u. 0C3ry . C ,.... „ J J T'i' OCCL;^. °_D ee . 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH November 14, 2016 07:52 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) Gary Settle, MD STANLEY S. 201804144 ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 14a. INFORMANT -NAME Phyllis Jane Bartu 16d. CEMETERY, CREMATORY OR OTHER LOCATION Douglas Grove Cemetery DUE TO, OR AS A CONSEQUENCE OF: b)Metastatic Adenocarcinoma Unknown Primary 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could net be determined 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NC. CITY/TOWN b. UNDER 1 YEAR MOS. DAYS 80 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA I i'd. COUNTY OF DEATH I Lancaster 9c. CITY OR TOWN Grand Island 9e. APT. NO. HOURS OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 1 9f. ZIP CODE 68803 Married ❑ Never Married I lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Divorced ❑ Unknown Phyllis Fisher 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Joyce Havlik b LICENSE NO. 1397 CITY / TOWN Comstock respiratory arrest, or ventricplar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a fine. Add additional lines if necessary. IMMEDIATE CAUSE: a) Cardiopulmonary Arrest 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger Pedestrian Other(Specify) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.) Male November 6, 2016 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr, STATE MINS. 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES EI NO ❑ PROBABLY ❑ UNKNOWN ❑ YES NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gary Settje, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 Cor February 13, 1 I .4h. TIME OF DEATH 6 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT 16c. DATE (Mo., Day, Yr.) November 15, 2016 STATE Nebraska 176 Zip Code 68801 CAUSE OF DEATH (See instructions and examples) . PART 1. Enter the thaw Of everts- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Immediately onset to dee 6 Months . onset to death onset trade h 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or investiga Ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) ❑ r 28b. DATE FILED BY REGISTRAR (Mo, . Day, Yr.) November 14, 2016