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STATE QF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISE� SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AIVD ,�,Il�l�.��RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD QN FILE WITH THE NEB�tASKA „��Aft NT,�'' ALTH AND
<br />HUMAN S�RVICES, VITAL RECDRpS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIT�C ;` ��7 , �
<br />� r 'rT - � �.'
<br />DATE OF ISSUANCE
<br />-•.,, ,,;` � � ��'L�.. +'�
<br />11 /09/2010 2 o i o u s o� 4 �TtUWLE.Y S . �o�,�� -- r, ,,�
<br />ASS�S''� NT 5�171E"RE,�I,�TRAR. �" ;'
<br />L'9� ��INT►�'F "�kJEA`L�'F� A�lVL7. • ' , �
<br />LINCOLN, NEBRASKA 7 °
<br />C)` it�,
<br />5TATE QF NEBRASKA - DEPARTMENT OF HH,4LTH AND HUMAN SERVIG�6 ;�r �' `� �� .�` j' '�� ,, �� O� Z�Z
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<br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Z. SEx '� _E��GF� QEA�'ry,�lp6., Day, Yr.)
<br />Ra mond WIIIiam Bartunek Male 1 "��,4pril2 01'0
<br />4. CITY AN� $TATE dR TERRRORY, qR FOR8IGN COUNTRY OF BIRTH 5a. AGE - Last 6lrthday h. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Y�'s•) MOS. DAY5 HqURS MINS.
<br />Bee, Nebraska 93 February 22, 1917
<br />7. SQCIAL SECIIRITY NUMBER ea. PLACE �F PEATN
<br />505-26-4629 N PITA � Inpatlent pTHER ❑ Nuning HomelL7C � Hoaplce Faclllty
<br />eb. PACILITY-NAME (H not Instltutlon, qlve streat and number) � ER/Outpatlent [] Dacadent's Hame
<br />K
<br />� 5aint Francis Medic�l Center [] a0a ❑ Other (SpecNy
<br />, W 8c. CITY OR TOWN OF DEATH (InGlude Zip Coda) � 8d. COU ���EA'I'FI
<br />a
<br />o Grand Island 68803 Hall
<br />a 9a. RESIPENCE•STATE 9b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />z
<br />LL 9d. S7REET AND NUMBER 8a. APT. NO. 8f. ZIP CODE 8a. INSIDE CITY LIMITS
<br />�, 2114 Brahma 5t. 88801 � ves ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH Q Married ❑ Naver Marrlad 70b. NAME OF SPOUS@ (First, Middle, I.ast, Su�Tix) If wHe, gNe malden name
<br />!� ❑ Marrlad, but sapanted � Widowed ❑ Divorcad [,�] Unknown Llizabeth Louise FiCk�
<br />m
<br />� 11. FATHER'S-NAME (First, Middla, Last, $u�Flx) 12. MOThIER'S-NAME (Flrst, Middle, AAalden $urnama)
<br />� William Bartunek Amelia Styskal
<br />� 1S. EVER IN U.S. ARMED PORGE57 GWa dates of sarvlca If Yes. 14a. INFORMANT-NAME 14p. RELATIONSHIP TO DECEDENT
<br />�ves, No, or unk.� Yes 04129/1942-02l07/1946 William Ra Bartunek Son
<br />� 15. METNO[l OF QISPOSITION 18a. EMeALMER•SIGNATURE 786. LIGENS� NO. 16c. DATE (Mo., Day, Yr.)
<br />� � BuHal ❑ Donatlon
<br />� Daniel D Naranjo 1071 April 29, 2p10
<br />❑ Cramation [] EMombment 78d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Rempval ❑ Other (3paClTy)
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />77a. FUNERAL HOME NAME AND MAILING ADDRES$ ($Vaet, Glty pr 7own, 3fate) 17b. Zlp Code
<br />All �'aiths �unsral Home, 2929 S. Locust Street, Crand Island, Nebraska 68801
<br />A F D ATM ee Instruct ons an exam les
<br />10. PAR71: EnNr th0 �d16Bai0i, inJll/iM, O� COmpllCaltlOni-thit dlroCtN CiUQld th! dB?th, �p NOT �mlr b�minpl We�t6lUGh i! prdlac arrea[, ; pppROXIMATE INTERVAL
<br />reiplfiWry d�re6t, O� VBnt�ICUlir flb�llldtlOn WkhOUt ihpwlnp iM etlplOyy. DO NOT ABBREVIATE. Enter OnN One caUq On a Ilne. Add addl[Ipnal Ilnu If nrcruary.
<br />IMMEDIATE CAUSE: ; onsat to death
<br />IMMEUTATE CAU8E (F�nal e) Cardiorespiratory Arrest ; Minutes
<br />dlcaam or condltlon raaultlnQ -
<br />In dsath� DUE TO� OR A5 A CONSEQUENCE OF: � onset to d6ath
<br />SequandaiN ��at condltiona, u b) AgB REleted D@CII118
<br />any, leadlnp to the aausa ueted
<br />on Ilnr a.
<br />DUE TO, OR A5 A CONSEQUENCE OF: : onset to daath
<br />Emer tha UNOERLYING CAUSE �)
<br />(tllwaw or I�lJury that InIt1iWU �
<br />thr rvanta raaultinp In drath) DUE TO� OR AS A CON5E�UENCE OF: : onset to death
<br />LAST d/
<br />18. PAR7 II.OTHER SIGNIFICANT CONDITIONS-Condltlons contrlbutiny to the death hut not resulting In the underlylnp cause plvan In PART 1. 18. WAS MEDICAL EXAMINER
<br />Bilateral Pulmpnary Emboli, Pelvic Fracture 2/10 And 4110, Right Pulmonary Infiltrate, Dementia, Malnutrition, C. Difficile Colitis OR CORONER CONTAC7ED7
<br />� Q YES � NO
<br />W 0. IF FEMq1.E: 21a. MANN�R OF DEATH 21p. IF TitANBPOit7A710N INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />�
<br />� � Not preqnant wkhln past year � Natural � Homiclda � Drlwr/Oparator Q YE$ � NQ
<br />� � PreynaM yt tlmo Of dBilh � qgCidlllt Q Pendinp Invssqpatlon ❑ PalNnpaY
<br />� Not proqnant, but propnaM wlehin A3 daya af death Sulclde Could npt be datsrminsd ❑ Pedaatdan 21d. WERE AUTOp$Y FINDING$ AVqILABLE
<br />� � NOt pYYpn9M, 6uf prvqnatlt 47 diy� t0 7 yoYY WfOYe tliAtll � � � othrr (Sprclry) TO CnMPLETE GAUSE OF DEATH9
<br />� � Unknown If prepnant wkh�n tha paat year ❑ YE$ ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Uay, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, atreet, factory, ottice bullding, construction slte, atc. (Specty)
<br />E
<br />�
<br />,� 22d. INJURY AT WORK9 22e. DESCRIBE HOW INJURY OCCURRED
<br />O
<br />� � YE$ Q NO
<br />22f. LOCATION OF INJURY -$TREET & NUMBER, APT.Np. CITY/TDWN STA7E ZIP CODE
<br />... _ ._._. 9 .�:. -. _= F�J1T1„��.�Qa�_ Yr.� . ..�.... ...�., . �.�.__ .. pp7E.4iG�o tuin_ nav_ vr_� . _ _ 71SAE�F�lEAi1L... _ -.-.---....__. .
<br />� � April 25, 2010 ��
<br />�� r 2Sb. PATE SIGN�D (MO., Day, Yr.) 23c. 71ME OF DEATH ��� 24c. PRONOUNCED DEAD (Mo., Day, Ya) 24d. TIME PRONOUNCED DEAD
<br />W � Ma 10, 2010 06:25 PM � e�
<br />$ U � 9d. To tha beat oi my knowladpe, death ouurrsd at tM qms, daro and placa $�� 24e. On tha bad� of axaminatlon and�or Invaatlyatlan, In my aplNOn dea�h vccurrsd at
<br />�� and dua ro tha cauw��) aWtea. (S�pnaturo and Tkle) $_� thv tlma, data and place and dur to thr uuw�f) �Wirtl. (Sipnaturo and T81r)
<br />~� Kimberly A. Mickels, Mp ~� a
<br />25, �ID TOBACCO USE CONTRIBUTE TO THE DEATM7 x8a. HA5 ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTEI79
<br />❑ Y�S � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applica6le N 26a is NO 0 YES ❑ NO
<br />. AN, ) ype or rint
<br />Kimberly A. Mickels, MD, 729 Nprth Custer Avenue, Crand Island, Nebraska, 68803
<br />28a. REGIS7RAR'S SIGNA7URE 28b. DATE FILEU BY REGISTRAR (Mo., Day, Yr.)
<br />May 10, 2010
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