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<br />WHEN THIS 'COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />12/30/2020
<br />LINCOLN NEBRASKA
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<br />202101455
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Joan Elaine Barton
<br />4. CITY AND
<br />STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Omaha, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-38-4387
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b'FACILITY-NAME °'(ht not Institution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />85
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ®Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 18625
<br />3. DATE OF DEATH (Mo., Day
<br />December 15, 2020
<br />Yr.)
<br />6. DATE OF BIRTH (Mo.Day, Yr.)
<br />April 27,-1935:: ;.
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND NUMBER
<br />819 E Delaware Avenue
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a: MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Samuel Bruce Barton
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle,
<br />Herrnan Dietrich Runge Lilian Whitehill
<br />Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Samuel Bruce Barton
<br />14b. RELATIONSHIP TO DECEDENT:
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑'Burial ❑Donation
<br />El cremation ❑ Entombment
<br />El Removal ` 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />December 17, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CITY / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />OF DEATH (See instructions and examples)
<br />14. PART I. Enter the chain of events. -diseases, Injuries, or complications that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Pneumonia Aspiration And Small Bowel Obstruction
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting:
<br />In death) -- DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<br />on title a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />5 Days
<br />onset to death
<br />onsetta death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1$, PARTS. OTHER SIGN(F(CANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Osteoporosis, Hypertension
<br />20. IF FEMALE:
<br />0 NM pregnant wKAin pastyear
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />n.:.Unknown 1*.pregnent. within the past year
<br />22a DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ECI NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />O YES 0 NO,
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eti
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 15, 2020
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 24, 2020
<br />23e. TIME OF DEATH
<br />07:37 PM
<br />23d. Te the hest of lily knowledge, death occurred at Inc time, date and pace
<br />And due 15159 cause(s) stated. (Signature and Title)
<br />Jane McDonald, MD
<br />25. 010 TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES 1E NO ❑ PROBABLY 0 UNKNOWN
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jane McDonald, MD, 800 N Alpha St, Grand Island, Nebraska, 68803
<br />ISP
<br />STATE ZIP.:CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurredat
<br />the time, date and place and due to the cause(*) stated. (Signature and mis)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />® YES ❑ NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO Ea YES
<br />©No
<br />28a. REGISTRAR'S SIGNATURE
<br />aji
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 27, 2020
<br />
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