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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH ANp HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA$!f4'DEPit:R7'"Mii~T OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO&:ttITf\:L'oRi:'I!}S, 11
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<br />. <. T - '. .' .
<br />DATE OF ISSUANCE . . 0" ,
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<br />OCT 2 0 200S'SiMJLEY S. J;QQPER .... .,',
<br />LINCOLN, NEBRASKA 200901192 .; ~:~;:it;G~~f~
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<br />STATE OF NEB. RASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES F1NAl':lQ. E ",!>iJj.\3. tJPftgfa..'I''r r. .,'. - 0 ')
<br />on, CERTIFICATE OF_DEATH~: '. ,.... ~,:1.:Hj .. 3 _,J 9 3
<br />1. DECEDENT'S.NAME (First, Mlddl., Lasl, Suffix) 2. SEX 3. DATE OF DEATH (Mo., D.y, Yr.)
<br />Robert Eugene Bartlett Male October 7, 2008
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<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />Riverview, Nebraska
<br />
<br />Sa, AGE-Last Birthday
<br />(Yrs.)
<br />73
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Day, Yr,)
<br />
<br />May 20, 1935
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-40-0769
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<br />8a. PLACE OF DEATH
<br />1::lO.SE!I,6,L: !lIllnpatlent
<br />
<br />QII:!fB: Q Nurelng Homa/LTC Q Hospice Facility
<br />
<br />FACILITY.NAME (If not inslltution, give slreet end number)
<br />
<br />Q ERIOutpatienl
<br />
<br />Q Decedent'. Home
<br />
<br />St. Francis Medical Center
<br />
<br />QOCli\
<br />
<br />Q Other (Specify)
<br />
<br />Be. CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />
<br />Gran~ Island,
<br />ge. RESIDENCE.STATE
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />303 West 4th
<br />
<br />68803
<br />
<br />~'~I~~~OUNTY Hall
<br />
<br />8d. COUNTY OF DEATH
<br />Hall
<br />
<br />lXMar;ied Q Nev.r Married
<br />
<br />... 19ZCITYOR TOWN
<br />~lda
<br />_-J9. APT NO 1~:PC6D;810
<br />
<br />10b. NAME OF SPOUSE (First, Middl., Last, Suflix) If wlfa, giva maiden name.
<br />
<br />[99.INSIDE CITY LIMITS
<br />Xl YES Q NO
<br />
<br />o Married, but separaled 0 Widowed 0 Divorced Cl Unknown
<br />
<br />Letha Newland
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<br />11. FATHER'S.NAME (First,
<br />Roy
<br />
<br />Middla,
<br />
<br />Laat, Suffix)
<br />Bartlett
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<br />12, MOTHER'S.NAME (First,
<br />Esther
<br />
<br />Middla,
<br />
<br />Maiden Surname)
<br />Christensen
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<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />13, EVER IN U.S. ARMED FORCES? Giva date. of servica if yes. 14a. INFORMANT-NAME
<br />(Ye., no, Or unk.) No
<br />15. METHOD OF DISPOSITION
<br />~Burjal 0 Donation
<br />o Cremation Q Entombment
<br />
<br />
<br />Bartlett
<br />rb LICENSE NO.
<br />/"'?Yt?
<br />
<br />CITY !TOWN
<br />
<br />16c. DATE (Mo., Day, Yr.)
<br />
<br />October 10, 2008
<br />STATE
<br />
<br />o Removal
<br />
<br />o Other (Specify)
<br />
<br />Cairo, Nebraska
<br />r7b~ Zip Coda
<br />68801
<br />
<br />Mount Pleasant Cemetery
<br />-. -......-
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streol, City orTown, Slata)
<br />Apfel Funeral Home, 1123 West Second,
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<br />PART I. Enter the ~tJ.--disea.sesr injuries, or compllcatioM--lhat directly caused the death. DO NOT enter terminal even Is such as cardIac arrest,
<br />respiratory arrast, or venlricular Ilbrillation without showing the etiology. DO NOT ABBREVIATE. Enter only One causa on aline. Add addltlonallinas if nec.ssary.
<br />IMMEDIATE CAUSE;
<br />(\. .
<br />(a) \Jl~~ ~ ~~
<br />DUE TO, OR AS A CONSEelGENCE OF: .
<br />
<br />onsel to death
<br />
<br />IMMEDIATE CAU6E (Fln.1
<br />dl......r condition resulting
<br />In death)
<br />
<br />-(/l.A-M1\....
<br />I,
<br />
<br />on..tto death
<br />
<br />Sequtntially liatconditions, If (b) . ~~ ~'V'-..t.~l..Oo...~
<br />any, leodlng loth. caua. tlsted ---. 6-UE T'O '(lR AS A CONSEQUENCE"OF' "..
<br />on~L ' .
<br />Enfer tho UNDERLYING CAUSE
<br />(dl..... or Injury that initlatod (e)
<br />theovanteresulfinglndeeth) DUE TO, ORASAC:ONSEQUENCE OF:
<br />LAS!"
<br />
<br />onset I. d..th
<br />
<br />onset 10 death
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Conditlone contrlbuling to the death bUI not rMulling In the undarlying cause givan in PART I.
<br />
<br />\~&\~:""l
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<br />,
<br />DI'~
<br />
<br />~;~~~
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<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />Q YES NO
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<br />20. IF FEMALE:
<br />Q Not pr.gnant wllhln pa.t year
<br />Q Pregnant at time of death
<br />Q Not pregnant, but pregnent within 42 day. of death
<br />Q NOI pregnant, but pregnant 43 days to 1 year before death
<br />D Unknown if pregnant wIthin the paSl year
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<br />21 a. MANNER OF DEATH
<br />~ Natural 0 Homicide
<br />
<br />Q AccidentU Pending Investigation
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<br />21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />Q Driver/Operator
<br />
<br />U Passenger
<br />
<br />Q YES
<br />
<br />~NO
<br />
<br />o Suicide 0 Could not be determined
<br />
<br />o Pedestrian
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<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />;'," ';
<br />
<br />'22A. oAl'EOFINJuR\' (M6..0at, '1'1.)' ..
<br />
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />
<br />. c- ~.....,l"- ..L___________----.--.-CJ..~E_~ )1l NO
<br />,.. ~Uii.J>ta;",. ,~""_Nhoni&;_ .-;~....'b6Itllnt;elIrYat~ttli: eIC.ISpoolfy)
<br />
<br />Q Olher (SpeCify)
<br />
<br />22d. INJURY AT WORK?
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />Q YES U NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYIfOWN
<br />
<br />$TATE
<br />
<br />ZIP CODE
<br />
<br />23a. DATE OF DEATH (Me" Day, Yr.)
<br />____\~ ---- '\ -O~
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<br />24a. DATE SIGNED (Me" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
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<br />'acne::
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<br />lif:~~
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<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 240. TIME PRONOUNCED DEAD
<br />
<br />m
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<br />248. On the basis of examination and/or invesligatlon, In my opinion death occurred at
<br />IhaUme, date and pleca and due to the cause(s) slaled. (Signature end Tille) ,.
<br />
<br />~
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<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
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<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />---.9...,,~.S.~~~.!ROBABLY Q UNKNOWN._Q_Y.~~__.____. )l NO n.. ~.Applicable If 26a is NO Q YES .Q(NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICiAN OR COUNTy..tl7D.RNEY) (Type or Print)
<br />Anne K. Morse M.D. 729 N. Custer Ave., Grand Island, NE. 68803
<br />
<br />280. REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />OCT 1 6 2008
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