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n n, C. rn C N N N cl� r) 2003111 4 5 -� r tiS i G COD WHEN TM COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SEIMCES SYSTEJK IT CERTIFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL -�01NFILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT "At UP !1;�__i1 CH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. - _ t " DATE OF ISSUANCE J DEC 6 2001 2003111#6 A,ss1STAHT' STJtT£�(Tl� LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICEOV! STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAXSERVIICE tai NGE ANb vrrAL STAnsfics CFRTIFICATF OF DEATI `- ---- =' n U: O -4 —1 M, r" �3 01 1?qR,� 1 DECEDENT -NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH /Month. Day Year) Robert Bartlett Male November 13 2001 a CITY AND STATE OF BIRTH lit notin USA.. name country) IN THE PAST 3 MONTHS? Sal AGE -Las[ Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Yearl Sb. MOS DAYS Sc. HOURS MINS 26a (Yrs.) 26c HOUR OF INJURY Riverview Nebraska Accident ❑ Undetermined J _._ 7 SOCIAL SECURTIY NUMBER M Ba. PLACE OF DEATH Suicide Pending 508 -30 -4341 261. PLACE OF INJURY - At home. farm street factory HOSPITAL ❑ Inpatient OTHER Nursing Home Homicide Investigation ❑❑ Yes No ❑ ❑ ER Outpatient ❑ Residence 8b FACILITY - Name fly notrnstlturI give street and number) 1 Tiffany re Care Center 27A. DATE OF DE TH (MO. Day Yr) ❑ DOA ❑ Other (Specdvl Bc CITY TOWN OR LOCATION OF DEATH 28b TIME OF DEATH 8d INSIDE CITY LIMITS 8e COUNTY OF DEATH Grand I 1 M — Yes ® Nu ❑ Hall Count E. RESIDENCE - STATE 9b COUNTY 28c PRONOUNCED DEAD IMO.. Day. YrJ 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER /Including Zip Code) 9e INSIDE CITY LIMITS Nebraska Hall oN gz Grand Island 3119 W. Faidley, 68803 1 Yes � No ❑ 10 RACE - leg.. White. Black. American Indian 11. ANCESTRY in q Italian. Mexican. German. etc) 12 ® MARRIED ❑ WIDOWED 13 NAME OF SPOUSE (It wile give maiden name) etc) ISpecify) White ISPec fY) American ❑ MARRIED DIVORCED Emigene Christensen _ ION (Give klndol work done during most '. tGb KI ND OF BUSINESS INDUSTRY 16 EDUCATION (Specify only highest grade completed) Eleme —, or Secontlary 0 121 College 11 .G o" S• n it refired) tk DID TOBACCO USE CONTRIBUTE TO TH ATH? Spa HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'/ Farmer 11 YES 1:1 NO UNK WN Agriculture ❑ YES NO Un�c 7uSUAL FIRST MIDDLE LAST '." OTHER FIRST MIDDLE MAIDEN SURNAME NMI Bartlett Alice NMT MrrA-xms IR WAS DECEASED EVER IN US. ARMED FORCES? t9a. MFORMANT NAME 'Yes no. or unk.) (II yes. give war and dates of services) No Fii ene Bartlett 19b INFORMANT MAILING ADDRESS ISTREET OR R.F D NO.. CITY OR TOWN. STATE. ZIP, . 69 Kuester Lake Grand Island Nebraska 68801 20 EMBAL ER - SIGNATURE & LICENSE NO 21 a. METHOD OF DISPOSITION 21b DATE 21C CEMETERY OR CREMATORY NAME '� c�Bdnal ❑ Nov. 17, 2001 Aurora Cemetery o Rem,,,,, - , CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE 22a NERAL H ME NAME kleine Funeral Home ❑ Cremation ❑ Dorar,,,. Aurora Nebraska 1 f j I 1Cb YUrvtMHL HVM[HUUnCJJ IJ�n[[t Vn n.r.U. �xV.. i.��r Un iv.r��. ,��nic,c I 3213 W. North Front Street. Grand Island, Nebraska 68803 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR gal. Ib). AND (cl) Interval between onset and neat, Ib) OR AS A CONS6DUENCE OF r Inlervw oetween onset and scan• Interval between onset and deal), (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART It IF FEMALE. WAS THERE A 24 AUTOPSY WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER' II (Ages )0 -541 Yes 171 No Yes No Yes No 26a 26b. DATE OF INJURY /Mo.. Day Yr.) 26c HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED . Accident ❑ Undetermined M Suicide Pending 26e INJURY AT WORK 261. PLACE OF INJURY - At home. farm street factory 26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE Homicide Investigation ❑❑ Yes No ❑ office building. etc. lSpecilyJ 27A. DATE OF DE TH (MO. Day Yr) 281 DATE SIGNED (Mo Day Yr) 28b TIME OF DEATH M — $ u—, r b. DATE SIG ED /MO.. Day Yc/ c. TIME OF DEATH 28c PRONOUNCED DEAD IMO.. Day. YrJ 28d. PRONOUNCED DEAD (Hour) as oN gz g F —12:00 Noon M ° M d. To the best of my, knowled death occ a at the time, date an place and due to the 28e. On the basis of examination and or Investigation. In my opinion death occurred at _ ° a° ° a causels, stated. '. the time, date and place and due to the causels) stated. Signature and Title) ► (Signature and Title) ► tk DID TOBACCO USE CONTRIBUTE TO TH ATH? Spa HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'/ b WAS CONSENT GRANTED'( 11 YES 1:1 NO UNK WN ❑ YES NO ❑ YES NO 31 NAME AND ADDRESS OF CERTIFIER fPFOSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY; rType or Prnp - Gordon j, Hrnicek Mp, 729 N. Gist r Gradd land Nebraska 688 32a REGISTRAR 32b DATE FILED BY REGISTRAR /Mo. Day. Yr.) k&t4r-o . -tv NOV 2 6 2001 I.. o rry N ,=..,. CD O C3, wN F—� i� A r Lots Fourteen (14) and Fifteen (15), having a lake front footage of 180 feet situated on the East side of the West Portion of Kuester Lake, and being on a.part of the East Half of the Southwest Quarter (E1 /2SW1 /4) in Section Thirteen (13), Township Eleven (11) North, Range Nine (9) West of the 6th P.M., Hall County, Nebraska.