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<br />STATE OF NEBRASKA
<br />IS -
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, iT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF:ISSUANi
<br />1 /24/2023
<br />GNCOLN,;NEDRASK)
<br />202!004`34 46044/4/
<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 />CERTIFiCA:TE OF DEATH
<br />1 11SCEDENVS'NAea What, Middle, Last, Suffix)
<br />TifflOthlf 'David ::Bartlett
<br />4. CITY AI
<br />D STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kemmerer. Wyoming
<br />T S(3CIA#.sECUNITYNUMBER
<br />506760.8451
<br />Ba, AGE - Lett Birthday
<br />(Yrs.)
<br />72
<br />i
<br />< .
<br />9b. FACILITY -NAME (M'not institution, give street and number)
<br />200 East Highway 34, Apt. Apt. #3075
<br />9c CITY OR TOWN OF DEATH (Include zip code)
<br />Grand Island 6801
<br />9a. RESIDENCS$TATE
<br />Nebraska .
<br />8d, STREET AND: NUMBER
<br />20 East F lghWay34
<br />9b. COUNTY
<br />Hall
<br />18a, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />Married, but separated ❑Widowed 0 Divorced 0 Unknown
<br />*1 FATHER'S -NAME (Firs, Middle, Last, Suffix)
<br />Artharw.DaVidgElartiett
<br />13.8YER iN Il.$ ARMED FORCES? Give dates of service if Yea.
<br />(Yes, No, or Unk) Yes 07/0311969-06/05/1973
<br />16. AAETHQD OF DlSPOSI#'ION
<br />(' Burial Q Dottai;on
<br />Cremation ❑Entombment
<br />tithed(Specify)
<br />3b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />23 00454
<br />3 DATE OF DEAaff. O., }lay Y(1 )::
<br />January 2, 023
<br />MOS.
<br />DAYS
<br />8a';PL4CE OFDEATH
<br />HQ TAL ❑ lnpadsnt
<br />0 ER/Outpatient
<br />© DOA
<br />9c. CITY OR TOWN
<br />Grand island
<br />HOURS
<br />MINS.
<br />8. DATE OF BIRTH:tMo., Day, Yr.)
<br />April 15, 1950:::,::::
<br />OTHER 0 Nursing Home/LTC 01.10.0ee Fap
<br />® Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />err
<br />9e. APT. NO.'
<br />,pt. #307E
<br />9f. ZIP CODE
<br />68801
<br />eg infi3E C0 ((hill'
<br />YES
<br />19b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name '
<br />Catherine Molczyk
<br />£ 12. MOTHER'S• -NAME (First,
<br />Jj Verna Lee Kuhn
<br />14a. INFORMANT -NAME
<br />Catherine Bartlett
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />lab. LICENSE
<br />ied. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />ha. FUNERAI: NOME NAME AND MAILING ADDRESS (Street, City or Toxin. State)
<br />At Faiths Funeral Home, 2:929 S. Locust Street, Grand Island .Nebraska
<br />NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />18a DATE tMo, Ds)r Yr )
<br />January
<br />CITY/ TOWN
<br />Gibbon
<br />18. PART I. Enter
<br />CAUSE OF DEATH (See instructions and examples)
<br />chain ofevents- aliases, Injuries, or compiications.het directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />, or velmiattler fibNIation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Lung cancer
<br />IMIti8D1A1t SAtiH£ (Final >.
<br />d aesae dr conaiortreat
<br />DUE TO, OR AS A` CONSEQUENCE OF:
<br />sequentially Net condhiona, If b)
<br />ellY, Mime toeel was Iffed..
<br />celine a
<br />DUE TO OR AS A CONSEQUENCE OF:
<br />Emiieuv UNDIRLTINdCAUSt C)
<br />(disease or injury t het Initisiai
<br />the events resulting in death),;
<br />DUE TO OR AS A CONSEQUENCE OF:
<br />d)
<br />la-PART,I1 OTHER SIGNIFICANT CO,NDrONS-Conditions contributing to the death
<br />Chronic Obatrirctive Pulmonary Disease, hypertension, heart failure, anemia
<br />24 IIf:FI
<br />❑ of pregns t, but pregh rt whhin 42 days of death
<br />❑ Not pregnen} but pregnant 43 days Uri year before death
<br />thdmawn IEsaegnata wbIde the peat year
<br />22a,'.cATE
<br />iFl
<br />IRI (Mab:; Day, Yr
<br />22f;fiocAT)ONf;OF INJUR1
<br />23a, DATE OF DEATH (Mo„ Day, Yr.)
<br />January 2,,2023
<br />21a. MANNER OF DEATH,
<br />® Natural 0 Homicide
<br />❑ Accidem 0 Penang Investigation
<br />❑ Suicide 0 Could not be determined
<br />TE IAL
<br />4 Months
<br />onset to death
<br />set
<br />not resuiting;In the underlying cause given in PART. I.
<br />22b, TIME OF INJURY
<br />21b. IF TRANSPORTA
<br />it ':Driest/operator
<br />0 Passenger
<br />,.. ❑ Pedestrian
<br />0 Other (Specify)
<br />TION INJURY
<br />22c. PLACE OF INJURY -At home, ;farm, street, factory,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />19. WAS MEDICAL EXAM
<br />OR CORONER CONTACTED?
<br />❑YES ENO
<br />21 c. Was AN AUTOPSY PERFORMED?.
<br />❑ YES ®NQ <
<br />21d, WERE AUTOPSY GS AVAiIAst.
<br />TO COMPLETE cAuSECIF DEATH?
<br />❑
<br />vas 0440
<br />netructtonaito,-efts (Si
<br />office building,
<br />TREET & NUMBER, APT,NO. CITY/TOWN
<br />DATE SIGNED (Mo., Day; Yr.) 23c. TIME OF DEATH
<br />)lartSlaly 5:'2023 03:42 AM
<br />•: iTti file sestst:n y knowledge" Math occurred et the time, date and place
<br />anti tlw to the causes) steed. (Blgnature and Title)
<br />Chart Vieth, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED
<br />246. On the basis of examination and/or investigation, in my opinion death oorturred et
<br />Iia time, date and place and due to the cause(s) stated. (signature .0 110.)
<br />24. DS/TOB0
<br />ACCO USE COi�NiTRIBUTE 1 O THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES NO L;i PROBABLY ® UNKNOWN : ❑ YES El NO
<br />2?. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO DYES El NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 17, 2023
<br />
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