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"EN THIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH SYSTEM R CERT FES THE BELOW TO BE A TRUE COPY OF THE OR/GIMAL, THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA TIM THE LEGAL DEPOSITORY FOR VITAL RECORD& DATE OF ISSUANCE NOV 301998 200406594. ,,, ; LINCOLN, NEBRASKA HEALTHANDHI4 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEI VITAL STATISTICS CERTIFICATE OF DEATH 4NLEV9cI€ MATE RE6ISh&# ST SUPPORT 1. DECEDENT . NAME FIRST MIDDLE LAST f' 3. DATE OF DEATH /Mont. Day. Yew) Filbert Frank Bartak Male November 2, 1998 d. CRY AND STATE OF BIRTH /Nno(h U.S.A. new couney) 5a. AGE • I "BWWay UNDER 1 YEAR 4NLEV9cI€ MATE RE6ISh&# ST SUPPORT 1. DECEDENT . NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /Mont. Day. Yew) Filbert Frank Bartak Male November 2, 1998 d. CRY AND STATE OF BIRTH /Nno(h U.S.A. new couney) 5a. AGE • I "BWWay UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /MOrMi.. Pay. Year) 5D. MOS, GAYS 8c. IiOURS � INS. nrs.l Clarkson, Nebraska 75 1 December 25, 1922 7. SOCIAL SECURTIY NUMBER Be. PLACE OF DEATH 507 -16 -8700 HOSPITAL: a In aa paa OTHER: ❑ Nursing Nora -- - ❑ ER 0lapuaN ❑ Residence .. 8b. FACILITY .Name /enwins"WLA'watoWww"Ithiw is St. Francis Medical Center ❑ GOA ❑ G"°r(Speeyl 8c, CITY. TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island I Yes © No ❑ I Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CRY, TOWN OR LOCATION 9d. STREET AND NUMBER /hcga,k y2go COW) 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 412 S. F4dv St. 68801 Yea 0 Na ❑ 10. RACE - leg., While. Black. Amariew Indian. 11. ANCESTRY le.g.. Italian. Mexican, GarnwrL idol 12. ® MARRIED ❑ WIDOWED /e ads. gate nwiden rwnle) sk.l lSpacilyl White ISpaceYl NEVER DIVORCED I Czechoslovakian II&NAMEOFSPOUSE Celestine A. Kloke 14A. USUAL OCCUPATION /Glw kind d wJra WM daft rrrOef 14b. KIND OF BUSINESS INDUSTRY N (Spec raft cornp atedl of working Aft awe 0reaadl Salesman a 8 ry a•,z1 Dae•w I,.4a5•I ri�� Vacuum C n 16. FATHER - NAME FIRST MIDDLE LAST ,7. MOTHER FIRST MIDDLE MAIDEN SURNAME Frank Mary Janda nBartak 16.1 WAS A ED EVER IN FORCES? .war 11�26�1942 19a INFORMANT -NAME gU ear r unit.) an i �Ml Yes World War II 11/27/1945 Celestine A. Bartak 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE. ZIP) 4 2 S. Eddy Street, Grand Island Nebraska 68801 20. ALMER - SIGNATURE 6 ENSE 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME 1236 ©Bur41 ❑ gal Nov. 6 1998 1 Grand Island City Cemetery a. FUNERAL HOME -NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE A fel- Butler - Geddes F.H. ❑' ❑°on' Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR RF.O. NO.. CITY OR TOWN. STATE, M 1123 W. Second Street, Grand Island, Nebraska 68801 21 IMMEDIATE CAUSE (ENTER Y ONE CAUSE PER LINE FOR lab (b). AND (ejI I Inlerval btivrpn or" and death PART v DUE TO, OR AS A CON EOUENCE I X Interval be~ or" and death poll ro)� DUE TO. OR AS A CONSEQUENCE OF: I bNween area and death X Iz Ic) I OTHER SIGNIFICANT CONDITIONS - Condisons coraibaing to the death bug not nNwd PART PART IN IF FEMALE. WAS THERE A 2a. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL II � PREGNANCY N THE PAST 3 MONTHS? X /( EXAMINER OR CORONER? (Ages 10 -541 Yes No Y. No Yes R NO 26a. 26b. DATE OF INJURY /MO.. Day. Yr.) 28a HOUR OF INJURY 28d. DESCRIBE HOW INJURY OCCURRED Accident U idetil -ned El Suicide Pending M 260. INJURY AT WORK 26f. PLACE OF INJURY -.N horns, lam. mail. facbry olNCe Dlaldin9. /SPsel6') 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN - STATE Homicide Inveaagation Yea ❑ NO ❑ 27a. DATE OF DEATH Wo.. Day. Yr.) 26a. DATE SIGNED (Mo.. Day. Yr) 28b. TIME OF DEATH a< 11 -02 -98 a M `rrs < } 27b. DATE SIGNED (Mo.. Day. Yr.) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD /Mo. Day, Yr.) 26d. PRONOUNCED DEAD (How) M 276 To the bef of my knowledge. death red a she line, dtle place and due b the 20e. On the Dasia d examination and,or investigation, in my opinion loam occurred at F � v cause(s) stated. y „/� A a the Nrtw. dale and place and due to IM Oause(sl aced. (S nature sntl Title re and Title 29, DID TOBACCO USE CONTRIBUTE TO H? 3D.a HAS ORGAN OR TISSUE DONATION BE CONSIDERED? 30b WAS CONSENT GRANTED? X ❑ YES ❑ NO UNKNOWN X ❑ YES NO K YES Y�l NO 31. NAME AND ADDRESS OF CERTIFIER ( PHYSIGAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI ITypeorPdrid Iftekhar Bader, MD, 2620 W. Faidle A e. Grand Island, NE 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR /MO.. Dey V 23