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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CAF?N/ES THE RAl$ED SE�F,�;� NEBRASKA HEA
<br />SY$TEM, lT CE'F7TIFIES THE BEL pW TO BE A TRUE COPY pF THE ORIG
<br />THE NE'BRASKA HEALTH AND HUMAN SERV/CE$ SYSTEM, VITAL S�7
<br />THE LEGAL DEPDSITORY FOR VITAL RECORDS.
<br />�
<br />DATE pF ISSUANCE J �
<br />mN�c o� 70�� 2 O 10 U 9 U 2 4 ��
<br />LINCOLN, NE9RASKA yyHT�l
<br />�� rs
<br />STATE �F NEBRASK/A - DEPARTMENT OF HEALTH AND HUMAI�'B�Z
<br />�r��,��rv�c�s -
<br />�I'�p��Jp� FI{� INITH
<br />7� `��ld�l,!�lIC�-115
<br />,�.�...� �,,, .� ,� ,�,;
<br />� ��� �✓;
<br />,r� � ��� ��d
<br />��FI AIVL7 FIL1MiAN SE�1y'��
<br />. .rt.,. . �w. . � : �
<br />7. OECEDENTS-NAME (Fint, Middl�, Laat, SuTllx) 2 SEX '� ��e Y ��qq�TC; OF TH� o.,Day,Yr.)�
<br />. u�": � ( ,, � � .
<br />Elixabeth Louise Bartunek Female � `, � `•` �"F�rtf / "Z2, 2008
<br />4. CITY qN0 STATE OR TERRITORY, OR FO/tEItlN COUNTRY OF BIRTM 6e. AGE-la�t B�rthday 64. UN�ER 7 YEAR 6c. IINDER 1�DAY e. pATE�GF BIRTH (Mo., Oay, Yr.)
<br />� (Yn.) MOB. DAYS HOURB MIN&
<br />David C Nebraska
<br />7. SOCIAL SECUWTY NUMBER
<br />5o�-os-z� �a
<br />Bb. FACILITY•NAME (R not In�tltutlan, giva atreat end number)
<br />Lakeview-A Golden Living Center
<br />8e. CITY DR TOWN OF DEATH Qncluda Zip Coda)
<br />Grand Island 68801
<br />9a. RESIDENCE-STATE 9b. COUNTY
<br />Nebraska Hall
<br />9d. STREHT ANU NUM6ER "� �•'�•
<br />2114 Brahma St.
<br />1 Ga. MARITAL STATUS AT TIME OF DFATH � Marrled Q Nwnr Mai
<br />❑ MeMod, 6u! a�peraled ❑ Wldowed ❑ OWorcad ❑ llnknown
<br />11. FATHER'8-NAME (Ftrst, Middl�, Wt, Sufllx)
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<br />87 � �
<br />8a. PLACL OF oEATH
<br />HQ,�p��;�[] InpaGam
<br />Q ERfOulpatlrnt
<br />[] DOA
<br />February 29, 1920
<br />IIItlE[i;, � Nurslnp HomdLTC [] Ho�plc� Facll�ty
<br />Q DxadaM'� Home
<br />[� OtheryBpsclty)
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9r. APT. NO. 9t. ZIP CODE
<br />68807
<br />10b. NAME OF SPOUSE (flnt, Middlr, 1aat, Sufllx) H vAte, qive maldan nam�.
<br />Ra mond Bartunek
<br />7R, MOTHER'8-NAME (F�ny Mmdl�, Maiden Sumams)
<br />Irene Schramek
<br />11. E1IER IN U.S. ARMEU FORCE87 Glva datar m�arvic� I( Yu. 7�a, INFORMANT�IJAME
<br />�vas, No, or unk.► No Ra mond Bartunek
<br />16. METHOG OF DISPOSITION 16e. EMBALMER-81aIqTURB
<br />�6u(1�1 ��OMtI011 �� I� 4R,��
<br />�r r,� �..�
<br />�cra�uuon �Entvmbmam
<br />����� �� 18d. C METERY, CREMATORY OR OTHER LpCATION
<br />Wastlawn Memorial Park Cemetery
<br />17a. FUNHRAL HpME NAMR AND MAILING ADnRES9 (Stnrt, City or Tawn, SMta)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />186. LICENSE NO.
<br />/�97
<br />CIT1'lTOWN
<br />Grand Isiand
<br />CAUSE OF DEATH See Instructions and exam les
<br />��. nnaT 4 Em�r uM ehnn m.v.nn _ a�..�.�., INurN�, or eomone�uon�-mae einniy ca�ra m. d..m, pp MaT mar umun�i �wm� ���n.. �.rdNw �mm,
<br />mp4�Mry uRq, of wntACUW OEIfIWfon wHhout �hoW�np ph �o1o0y. DO NOT ABBRCVIA7E. Enhr anly o�x c114N on a Iln�. AtlE atlAldonN IIM� H n�e�Nlry.
<br />iMMEOUre causE:
<br />IMMEqWTE CqUBE (Final
<br />dl�eue ar candldon roaulGnp a) �'^le,� \ � : ` � �,
<br />in da�th)
<br />� tiUE TO, OR AS A CONSEqUENCE OF:
<br />Saquan8ally Ilet aondlllona, Ii j�� 1 f
<br />any, leedlnp to tha cau�e Ilatad 4) ("`� ��"' 1���+ �� v.� [.� ��� t i
<br />on Ilne a. DUE TO, OR AS A CON$6QUENC� OF: �. � �.�
<br />Emar thr UNUERI.YING CAUSE �)
<br />(diwur ar InJury that Initlatad
<br />an rv�nh roaulUnp In death) DUE TO, OR A$ A CONSEpUENCE DF:
<br />LAST
<br />d)
<br />1B. PART 11. OTHEN SIaNIFICANT CONpiT10N8-CondiGon� corMribuanp ro m� d��th but not reauldnq In 1h� und�dyinp wuss plvsn In PART 1.
<br />I �.� �
<br />� 70. IF FCMALE: ZiL MANNER pF �EpTH 27b. IF TRANSPORTATION INJUi
<br />li.
<br />� �Nat prpnant wllhin peat ysur �Nalurnl ❑ HomiNrN ❑ DHvaHOparrtar
<br />� ❑ Prrgnant �t Gms oi deeth ❑ Accidant ❑ Panding Inv�appepon ❑ Puwnpv
<br />U
<br />❑ Noe propn�nt, but praqnant w�thin az daya of daath ❑ Sulcida ❑ Could not ba dstamllnad Q Pw�afri�n
<br />� Q Not pnpnanf, but preqnrnt ba daya !0 7 yesr befon daath Q ptl��r (gp�cly)
<br />a �Unknown It prepnant w�th�n th� pase ysav
<br />�
<br />W
<br />a
<br />Yp. INSIUE CITY LIMITS
<br />� Yss Q No
<br />14d. RELATIONSHIp TO UECE�ENT
<br />Husband
<br />78c. DATE (Mo., Day, Yr.)
<br />February 27, 2p08
<br />STATE
<br />116. Lp Cade
<br />68801
<br />APpROXIMATEINTERYAL
<br />�
<br />I ona�t ta d�ath
<br />i (�� �-�.�,�.--� -
<br />onrrt to daeth
<br />�
<br />I Z 3 w 14s
<br />on�at w death
<br />�
<br />I
<br />1 on�attv dr�m
<br />�
<br />79. WA8 MEPICAL EXAMINER
<br />OR.CORpNEq CONTACTED9
<br />0 YES � ry0
<br />T �
<br />21c. WAS AN AUT SY PERFORMED7
<br />❑ YES (JO
<br />R1d. WERE AUTOPSY FINUINpS AVA11,,,qBLE
<br />TQ CpMPLETE CAUSE OF DEATH7
<br />❑ YES � ND
<br />� 22�. OA7E OF INJURY (Mo., Day, Yc) 226. 71ME OF INJURY 12c. PLACE OF INJURY-At homs, Tenn, �treat, tactory, oNic� 6ulldlnp, ronstrucUon aite, etc. (Spaciy)
<br />CJ
<br />d
<br />m 22d. INJURY A7 WORK7 �2s. DESCRIB@ NOW INJURY OCCURRE�
<br />0
<br />F" Q YES ❑ NO
<br />22f. LpCATION OF INJURY � STREET & NUMeER, APT. Np. CITYlTOWN STATE ZIP GOOE
<br />13e. DpT� OF �Eq7H (Mo., pay, Yr.) z 4 TAa, ppTE 816NE� (Mo., D�y, Yr.) 24d. TIYE OF DEATN
<br />�� �'ebruary 22, 2008 ��� ,�
<br />� y 29h. ppTE SIGNEn (Mo., 5ay, Yr.) S3c. TIME OF DEATW p� � O 2�IC_ pItONOl1NCE� DEqq (MO., �Ily, Yr.) 24d. TIME PHpNOl1NGEU UEAD ;
<br />� �O Z- � - 7 - '�L � °7 G-�cr'� Q � : � 0 � . 11'1 � y � _ �p
<br />y 23d. To the be�t oi my knowl�dg�, death accurrad at the Gma, dea �nd plac� � y�j Z Q 2qa. On tha n�a�s or axnminallon �ndlor Inwatlpatlan, in iny opinion daath occurrrd
<br />+�+ � and dur to ai� uuae�s) stetad. �Siqneture and Titla� � Z p n the Gme, dete and plecr and du� ro fhe ceusa�s) efatad. (S�pnrtun and Tlpe)
<br />~ � � ; -u. ��G � ��
<br />�o
<br />Y6, n10 TOBACCO USE CONTRI84TE TO THE UEATH7 28e. HAS OROAN qR 718SU� IIONATION BECN CONSInERE47 98b. WAS CONSENT 6RANTEn7
<br />❑ YES �NO ❑ PROBABLY ❑ UNKNOWN ❑ YES NO Not Apqlc�61� If S8� Is NO ❑ YES Q Np
<br />R7. NAME, TITLE ANO ADDRE85 qF CERTIFIER (PHYSICIAN, CORONER'9 PHYSICIAN OR COUNTY ATTORNEY) (7ype ar Print►
<br />Donald Wirth, M.D., 2116 W. Faidley Ave.,�x'and Tsland, NE 68803
<br />28�. REGISTRAR'S SIGNA7'URE � 28b. �ATE FILEO BY REp18TRAR (Mo., Dey, Yc)
<br />,�. MAR 3 2008
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