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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />
<br />:::;:~::::::;TORY FOR VITAL RECORDS, MA1~J.. '.." :/!~flN
<br />20070 7 0 5 7 ;vV'"' "71TANLEY-S. COOPER
<br />AUG 0 9 2007- ASSI$..rA.NT STAT~ REGI$r:RiR
<br />LINCOLN, NEBRASKA HEAL!!! ANt) HI.J.flIIAN SERV/~E5
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES F1l\IANCE'ANO"$lljieOJIT.....2;o3 4: 8
<br />CERTIFICATE OF DEATH -: - . u r - '0
<br />
<br />1, DECEDENT'S-NAME (First, Middle,
<br />Robert Arthur Barrett Jr
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />2. SEX', . ,_ 3. DAJlOF DEATH' (Mo.. Day, Yr.)
<br />Male- :'" ,t:!. . Jul9'g, ~607
<br />
<br />5c, UNDEF:rt DAY: e. DAtE OFalRTH (Mo.. Day, Yr,)
<br />HOURS I MINS.
<br />
<br />July 31, 1945
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />Sa, AGE-Last Birthday
<br />(YrS,)
<br />
<br />5b, UNDER 1 YEAR
<br />MOS, I DAYS
<br />
<br />\
<br />
<br />Grand Island, Nebraska
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />505-54-3436
<br />eb, FACILITY-NAME (II not Inatltutlon, give atreet and number)
<br />
<br />61
<br />
<br />ea, PLACE OF DEATH
<br />J:l.Q,S,fJJAl.:
<br />
<br />o Inpallenl
<br />
<br />QlliEB: 0 Nursing Home/LTC 0 Hoaplce Fadllly
<br />
<br />IllI ER/Oulpatlent
<br />
<br />o Decedenr, Hema
<br />
<br />is
<br />..J
<br />0<(
<br />~
<br />!l!!
<br />it
<br />i
<br />'"
<br />.lI!
<br />
<br />~
<br />111
<br />'l!l.
<br />~
<br />II
<br />~
<br />
<br />Saint Francis Medical Center
<br />
<br />ec. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Grand Island 68803
<br />9a. RESIDENCE-STATE
<br />
<br />Ill>. COUNTY
<br />Hall
<br />
<br />19c. CITY OR TOWN
<br />
<br />Grand Island
<br />lee. APT. NO lef.ZIP CODE
<br />
<br />68801
<br />
<br />lOb. NAME OF SPOUSE (First, Mlddla, Last, SUfllX) II Wife, give maiden name.
<br />
<br />leg.INsIDE CITY LIMITS
<br />Ij YES 0 NO
<br />
<br />1:1 ro\ Q Oll1er(Spadly)
<br />18d. COUNTY OF DEATH
<br />Hall
<br />
<br />Nebraska
<br />ed, STREET AND NUMBER
<br />
<br />108 West 15th Street
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH liD Marrlad 1:1 Never Marned
<br />
<br />Q Marnad, but separaled 0 Widowed Q Dlvorcad Q Unknown
<br />
<br />Lois Blume
<br />
<br />Sulllx) 112' MOTHER'S-NAME
<br />
<br />Bettv Butcher
<br />
<br />11. FATHER'S-NAME (Flret,
<br />
<br />Mlddla,
<br />
<br />Last,
<br />
<br />(First,
<br />
<br />Middle, Malden Surname)
<br />
<br />Robert Arthur Barrett
<br />13. EVER IN U.S. ARMED FORCES? Glva datu 01 servlcellyaa, 114a.INFORMANT.NAME
<br />(Yea, no, orunk.) Yes 06/17/1964-06/14/1968 I Lois Barrett
<br />15. METHOD OF DISPOSITION 16e. EMBALMER.SIGNATURE
<br />Q Burial Q Donallon Not Embalmed
<br />II CremaUon Q Entombmenl 16d, CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />I 16b, LICENSE NO.
<br />
<br />
<br />CITY /TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />16c. DATE (Mo.. Day, Yr,)
<br />d'......hl /2,2007
<br />
<br />STATE
<br />
<br />Q Removal Q Other (Speclly)
<br />
<br />Central Nebraska Cremation Service
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streat, City or Town, Slate)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />Gibbon
<br />
<br />Nebraska
<br />
<br />117b. Zip Code
<br />68801
<br />
<br />CAUSE OF DEAT"R" (!fee InstrUctions and examples)
<br />16, PART I. Enter the chain 01 evenle--dlseases, InJunes, or CQmpllcatlonsnthat directly caused the dealh. DO NOT enter tal111lnal aventa such as cardiac arree~
<br />resplralory arresl. or ventricular Ilbnllatlon without Showing the eUology. DO NOT ABBREVIATE. Enter only one cause On a line. Add addlllonalllnes II necessary,
<br />IMMEDIATE CAUSE:
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />I
<br />I
<br />
<br />I onset to daath
<br />I
<br />I
<br />
<br />IMMEDIATE CAUSE (Fnal
<br />dleea.. or cmdRlon relUnlng
<br />ndeall'l)
<br />
<br />(a) multiple gunshot wounds
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I onsal to death
<br />I
<br />I
<br />I
<br />I onselto death
<br />I
<br />I
<br />
<br />8equenllally I'" <ondlllone, II
<br />.-,y, leading 10 the cau..lIsted
<br />on IIn...
<br />Enter l1a UNDERLYING CAUSE
<br />(dlsene or Injury llhallnlllalad
<br />Ihe ovente retuning n daall1)
<br />lASI"
<br />
<br />(b)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />I onselto dealh
<br />I
<br />I
<br />
<br />(d)
<br />
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS-Condltlona contributing to the dealh but nOI resulllng In the underlying cause glvan In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />)Q YES 1:1 NO
<br />
<br />fli 20, IF FEMALE: 21a. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY 21c, WAS AN AUTOPSY PERFORMED?
<br />... Q Q Natural 'tI Homlclda 1:1 Driver/Operalor
<br />!ij Not pregnant Within paelyear Q Passenger Xl YES Q NO
<br />~ Q Pregnant at time of death 1:1 AccldentQ Paneling InvasUgatlon
<br />Q Pedestnan
<br />j 1:1 Not pregnant, bul pregnant within 42 days 01 deall1 Q Suicide Q Could not ba dalel1111n9d 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />Q Olller (SpaClly)
<br />]] Q Not pregnant, but pregnant 43 days to I yearbelore deall1 COMPLETE CAUSE OF DEATH?
<br />
<br />f Q Unknown IIprelll'antwlthin Ihe pas I year XDt YES Q NO
<br />
<br />8 22a. DATE OF INJURY (Mo.. Day, Yr.) I 22b. TIME OF INJURY 1 22c. PLACE OF INJURY.Athome, larm, atreel, lactory, ornce building, conslructlon site, etc, (Speclly)
<br />! July 9.2007 11:00 pm Ihome
<br />
<br />~ 22d.INJURY ATWORK? 1 22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />Q YES ~NO IMr. Barrett Jr. was involved in a standoff with police and was shot after firing at them.
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITYfJOWN Sl)\TE ZIP CODE
<br />
<br />108 West 15th Street
<br />23a. DATE OF DEATH (Mo.. Day, Yr.)
<br />
<br />Grand Island
<br />
<br />NE
<br />
<br />68801
<br />
<br />24s, DATE SIGNED (Mo.. Day, Yr.)
<br />Auoust 1. 2007
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.)
<br />Julv 9 2007
<br />
<br />24b. TIME OF DEATH
<br />11:58
<br />
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<br />.u5~
<br />Ii _OIl: Z
<br />llffizO
<br />!~::>
<br />~8~
<br />
<br />~~
<br />112
<br />1i~
<br />i5.:J:~
<br />El>.z
<br />8 g'O
<br />.xl!
<br />.2~
<br />0<(
<br />
<br />. p m
<br />
<br />23b. DATE SIGNED (Mo., Day, Yr.) I 23c, TIME OF DEATH m
<br />
<br />
<br />23d. To tha best 01 my knOWledge, daoth occurrad at tha lime, data and place
<br />and due 10 the cause(s) stated. (Signature ond Title) "
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />11 ~ 58 D m
<br />
<br />p
<br />
<br />24e. On lI1e basis 01 examnaUon anel/or Invutlgatlon, In my opinion deall1 occurred at
<br />tha time, date and place and due 10 lha cous.(s) stated, (Slgp,ture,..llnd Tille)"
<br />-, ~ Ha I county
<br />.- ~) ~ Attorney
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? I 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERE~26b. WAS CONSENT GRANTED?
<br />
<br />Q YES )Q: NO Q PROBABLY 1:1 UNKNOWN Q YES riD NO '- . I Nol Appllcablel126a la NO Q YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIRER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Type or Pnnt)
<br />Mark J. Younq. Hall County Attornev 231 S. Locust Street Grand Island. NE 68801
<br />
<br />28a. REGISTRAR'S SIGNATURE jJ J I'
<br />
<br />I ,.,~~ ":JI'o ,(J. (~....
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />.AUG 6 2007
<br />
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