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, STATE OF NEBRASKA
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<br />', WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT� �11/D ��JMA�iI "�ERVICE$,, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA��CA�P��7Nf�a11 �1�J�{EALT,H AND
<br />I � HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR:�� GZ�� � r
<br />� • �. .
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<br />j DATE OF ISSUANCE J �� `� ���� ",� �
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<br />���.�������!�+� � ; ,t1 0 .�,.
<br />12/07/2010 SraAt���r� � P� , «, ; ,.
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<br />LIAICOLN, NEBRASKA HUaA�'IkklXd �,E{��lZCE'S e � ,a,
<br />STATE OF NEBRASKA - DEPARTMEPIT OF HEALTH AND HUMAN SERVTQES�� �� �'� 3'r��✓'�£ r �� �,�%
<br />CERTIFICATE OF DEATH " � ,� '�'�' �p� � 3 , 7�:a' , � 10 03518
<br />1. DECEDENTS-NAME (First, Middle, Last, 3uffbc) 2. SEX ,° °� ,3,�19�1TE pF.taEATH (Mo., Day, Y►.)
<br />' Dorls Lee Bartlett Female '•`. November,27; 2010
<br />4. CI1'Y AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Blrthday b. UNDER 1 YEAR Sc. UNDER 1 DAY B DATE OF BIRTH (Mo., Day, Yr.)
<br />I I n�•) MOS. DAYS HOURS MINS.
<br />' � ucson, Arizona 50 July 28, 1960
<br />I 7. &OCIAL SECURITY NUMBER 8a, pLACE OF DEATH
<br />06-72-9032 HOSPITAL � InpadeM OTHER � Nursing Home/LTC � Hospice Facllityr
<br />8b. FACILITY•NAME Qi not Ir�stitution, gfve street and number) � ER/OutpaUent � DecedeM's Home
<br />� O
<br />v � 122 S Eugene St ❑ DoA � Other (5pecf(y)
<br />� 8c. CIIY OR TOWN OF DEATH pnclude 2Ip Cudej Bd. COUNTY OF DEATH
<br />c ,,....11 Wrand Island Hall
<br />� 9a. E3IDENCE-STATE 9b. COUNTY 8c, CffY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 8d.,$TREET AND NUMBER 9e: APT. NO. 8f. LP CODE 8g. INSIDE CITY UMITS
<br />� � 1122 S Eugene St � res ❑ No
<br />.� 10a';, MARITAL 9TATUS AT TIME OF DEATH � Married � Never Marrted 10b. NAME OF SPOUSE (First, Middte, Last, Suffix) I} wifa, give malden name
<br />� �] nnamed, but separated ❑ v�ndowed ❑ oroorcea ❑ unkrrown Daryl Barttett
<br />� 11. FATHER'S•NAME (First, Middle, Last, Suffiz) 12. MOTHER'S (First, Middle, Malden Sumame)
<br />d F�rank Hoover Paula Wendt
<br />°' 73. �VER IN U.S. ARMED FORCES? Gire dates of service H Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� �Yes, No, or Unk.) No Daryl Bartlett Husband
<br />,�' 15. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F � Burial ❑ DonaUon
<br />Matthew T. Myers 1411 November 27, 2010
<br />0 Crematlon Q Entombment 76d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />[�] Removal ❑ Other (Specify)
<br />� Grand Island City Cemetery Grand Island Nebraska
<br />17a; FUNERAL HOME NAME AND MAIUNG ADDRESS (Streat, City or Tow�, State) 77b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CA S OF D H See nstructlons an exam les
<br />1& pART I. EMer the �atn oi evema•�Ilseases, InJuHes, or compltaaqo�re-that dUectly caused Ure death, pp NOT eMer lerminal eveirts such as eaMlac anest, ; qppROXINU►TE INTERVAL
<br />�reeplratory arteet, or ve�rtrleular flbdiladon without shmMng the eUOlogy. DO NOT ABBREVIATE EMer onty one cauae on a IOre. Add addidonal IOres if naceasary.
<br />IMMEDIATE CAUSE: ; o�et to death
<br />m+meoarecnuse�� 0 )Myocardiallnfarc�on ; Immediate
<br />d�seaseorconatHOnrwuitleg . . � --- -- -_ .;__. _._ ___. ___
<br />-.�..___. ..-- -
<br />�� �� DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />s�m��tyu8e�ano�,rc b)Chronfc Obstructive PulmonaryDiseasa 9 Years
<br />am; �eamne ro tne cause �I&ea ,
<br />on Il�re a
<br />, DUE TO, OR AS A CONSEQUENCE OF: 7 onset to death
<br />�erure unw�ruro cause �) Fibromyalgia : Years
<br />(dls9ase or in)ury that Initlated �
<br />Gre ¢veme reeutting In death) DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />� d) �
<br />18. PART tl. OTHER SIGNIFlCANT CONDITIONS-CorMitlo� cond9buting to the death but not reautting in the underlying cauae given In PART I. 18. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />W � YES ❑ NO
<br />� 20. t� FEMALE: 21a. MANNER OF DEATH 296. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED7
<br />F �'INOtplegnaMwithlnpaetyeaz � NaWrat � HomlWde � DNverlOperaWr
<br />'� W � PregnaM at dme ot death � Passenger ❑� � NO
<br />(� ���i � Auldem � Pending Imeatlgatlon
<br />Q', Not pregnam, but pregnarrt wkUln 42 days ot death � pedestrian 21 d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />� ,�' � swdde � CoWd not be determhred ❑ TO COMPLETE CAUSE OF DEATHY
<br />'o Q��� Not pregnaM, but PregnaM 49 days to 1 Year before tleatb OGter (BP���Y)
<br />� �� Q��, Unknown It preg�mrrt with�n the Past Yea�' .. � ❑ YES ❑ NO
<br />� Z2a• ATE OF INJURY (Mo., Day, Yr.) 22b. TIME,OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, oftice buliding, construction ake, etc. (Sp�ify)
<br />�
<br />.� 22d. �NJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />Q YES ❑ NO
<br />22L �.00ATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
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<br />� i 23a. DATE OF DEATH (Mo, Da_y, Yr,1 __, -__ --- - �-- __. 2�a. DAT� 31GNEL� (A4a., Day, Yr.) 34b. TlR!E QF bEd'i'H - - -
<br />s� ��� November 29, 2010 Approx. 01:00 AM
<br />� ° 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� y 24c, pRONOUNCED DEAD (Mo„ Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />�' z � a a Z November 27, 2010 10:06 AM
<br />$ ��� � 9d. To the beet of my knowtedge, tleath ocwrted et the tlme, date and pWce ��� p�, On the 6aels of eaaminatlon and/or imreatigatlon, ln my opinlon death occurretl at
<br />� aiM tlua to the ceuse(e) ataletl. (Signature and Title) .8 x
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<br />F� o C o the tlme, dale and place and due to the cause�s) sfated. (SlgnaWre and TiUe)
<br />� t� C :
<br />g o Lynelle Homolka, Hatl Deputy County Attomey
<br />26. D D TOBACCO USE CONTRIBUTE TO THE DEATH7 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDT 28b. WAS CONSENT GRANTED4
<br />Q YES ❑ NO ❑ PROBQBLY � UNKNOWN ❑ YES � NO NotApplicable H28a Is NO ❑ YE9 ❑ NO
<br />27. , �, TI D D ERTIFIE PHYSIC , SIC 1 , CORO S H SI OR C U ORN ype or riM)
<br />Lynelle Homolka, Hall Deputy County Attomey, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a. REGISTRAR'S SIGNATllRE � 26b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />December 6, 2010
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