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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A 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 />ITE OF ISSUANCE
<br />2/22/2023
<br />ah &L.uo,
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />8
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1: DECEDENTS -NAME (First, Middle, Last,
<br />Frances . IUllareeRr►e Bartunek
<br />Suffix)
<br />CERTIFICATE OF DEATH
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hoskins, -Nebraska.
<br />1. SIOCIAk SEGURITY`NUMBER
<br />507..4,.9655
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />86
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />8 Navaio'Drive
<br />. E1'(Y OR 1'OWN .01=1) .,,.
<br />Gland Island 68803
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />$d. &TREST AND NUMHEft
<br />8 Navajo Drive
<br />e Zip Code)
<br />105. STATUS AT TIM)
<br />but separated
<br />9b. COUNTY
<br />Hall
<br />tib. UNDER 1 YEAR
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />HOURS MINS.
<br />23 01930
<br />3. DATE OF DEATH (650, Dtly,Yrl:;:.
<br />February 7.;2023
<br />6. DATE OF BIRTH {Mo., Deyr Yr:)
<br />July 30, 1936
<br />OTHER 0 Nursing HomeILTC
<br />El Decedent's Home
<br />0 Other (Specify)
<br />18d. COUNTY OF DEATH
<br />Hall
<br />DEATH ❑ Married ❑Never Married
<br />tldowed 0 Divorced 0 Unknown
<br />11. FATHER S•NAME (First Middle, Last, Suffix)
<br />Reuben Voedcs<...
<br />13. &ERIN US ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />14 METHOD OF. DISPOStnoN
<br />j Burial 0 Dona(tpn
<br />Cremation ❑ pntonjbmett#
<br />QRemoval '' ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />9e. APT. NO.
<br />F€ltsptee FatdHly
<br />Sc•
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden.
<br />Dawayne Delvin Bartunek
<br />14a. INFORMANT -NAME
<br />Brandi M Lopez
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Irmel Bowman
<br />16b. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />17a. FUNERALHQMENAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths `un@ral Home; 2929 S. Locust Street, Grand Island, ,Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />IS. PART I•'Enter the chain of evente- .diseaeas, 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 it necessary.
<br />IMMEDIATE CAUSE:
<br />IMb1E01ATECAU$Eghns a)Unknown Natural Causes
<br />dlaaase or ddndlltod reauaing
<br />In death).:.
<br />saquentiSipr list conditions, if
<br />SOY, leat,(to.the cause ilatad•-
<br />on•
<br />the events resulting in death)
<br />LAST
<br />9g INSIDE CITY LIMITS;;
<br />® yes ❑ NO
<br />14b, RELATIONSHIP TO DECrEioeNT
<br />Granddaughter
<br />18c. DATE'(MM0 Oay;,Yr.) :.
<br />February 13..5023
<br />sTarE
<br />Nebraska
<br />17b Z(pgCode :
<br />68801
<br />(MATE INTERVAL
<br />onset tesd ti::
<br />Immediate
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 PisRT it OTiIIE.R 31t. ICA NTC ONDITIONS.Conditions'contributing to ttte:death but not resulting in the underlying cause given in PART I.
<br />Severe Chroltilo obstrUCtiye pulmonary disease, high blood pressure, atrial fibrillation
<br />20. IFFEMALE:;:
<br />Mot pregnant wlthM peat year
<br />❑ Pregnant at ime of death .
<br />Tlot pregnant: but pregnant within 42 days of death
<br />❑ Not pregnant; but pregnant ss days L51 year before death
<br />r�--77 Unknown if pregnant w thifl tits past year
<br />22a . ATE
<br />F'INJURY IMO Day, Yr,)
<br />22d. INJURY AT WORK?
<br />NO;:.:
<br />.... ........................... ...............
<br />21a. MANNER OF DEATH
<br />® Natural Q Homitido
<br />0 Accident 0 Pending InvsatlgsBen
<br />0 Suicide 0 Could notbe determined
<br />22b. TIME OF INJURY
<br />21b. IF, TRANSPORTATION
<br />©anv$r/operator
<br />© Pase/neer
<br />Q:.Pedestnan
<br />Q Other (Specify)
<br />INJURY
<br />onset to death
<br />19. WAS MEDI(rAL`EXAMINER
<br />OR CORONER CONTACTED? ?`
<br />® YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ( NO
<br />22c. PLACE OF INJURY•At home, farm, street, factory, office building, const uctibn she, ety {Spg
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22? LOCATiON OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH'(Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />cITYITOWN
<br />23c. TIME OF DEATH
<br />8d.
<br />TO:the- beat of my know ledge,death occurred at the time, date and place
<br />and due to lbs deuse(s) stated. (Signature and Tttle)
<br />2
<br />24• DID TOBACCO USE G.QNTRIBUTE TO THE DEATH?
<br />Q YES
<br />NON PROBABLY El UNKNOWN
<br />STATE ZIP GORE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />February 9, 2023
<br />24b. TIME OF DEATH
<br />Unknown
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />February 7. 2023
<br />24d. TIME PRONOUNCED DEAD
<br />09:25 AM
<br />24e. Op the haste of examination and/or investigation, in my ophtion oeogrred at ;
<br />Melina, date and place and due to the cause(s) stated. (Mynah's! tihi .3#ks►
<br />Williameete Gallagher, County Attorney
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />Q YES ENO
<br />27.NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Willamette Gallagher, County Attorney, 231 S Locust Street, Grand Island, Nebraska, 68801
<br />26b' WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO © YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />February 15, 2023
<br />
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