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r. STATE OF NEBRASKA a 01,4 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMEWZ ,~AWQ , 14UMAN SERVICES, I T CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGOL O#0 l~l FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICE g," AL'FI~C 3RD$ OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS ' DATE OF ISSUANCE D16 FM 2-7 G20iZ' T,L;E4' CfR y , r y A TAN`F S 7 AEbfST9AR ` ~E TJ~IE T,~$I J~F,ALTH A,~p . LINCOLN, NEBRASKA } H~, d ~4 ` ' 1 94 WATE OF ►-DVA ITOFe rN J; DUMN.OF WTAL stAtgam. v cERcATE OFE: ►t 7 . ~2 I. - 2 __1 Grand WAd S4 gMECAII$E PEA LaE 23. aAME0111TE ONL pTI.ItM, ANO(Cp - kPalYatplaraauOMafaa00aPl+ f C A PART I :CR _ - JUETO.ORABA OF - wean aaaaae Oars" agar. Y DLaf'(o.aR AGDN5E0uExWOP _ kambbatwommPCOno PtArWER CONOlY1fXi5•CgfOnrcs t7pa/'OtigOar "MArAa rblreMRaa PAAT12EfEMALE DAIS THERE A 74 AUTOPSY 7S wAS [ASER$ TO WMICAL a PREGN.UIlCY lR 7RIE PAST 3 MONMI FxM,IEA OR COAOaEp 31 « - G) lla a ; T ~ 1 ` . .~t ► ✓ T ~ 1494 'Yp ' 71 - Yea Ma - Ya. w 228 920 OATS OF *AM Ab DW YC1 HOUR aLLIUPV 22a OEm.RIeE NOW WJRY OCCURRED ❑ ❑ ❑ &Rm a 11 P-q M tea WURVATWOFtt ZsI P ACEOF ar Y Atlm,a. term. Wall be4Y 22g LQ;ATION STREET OR RFa 0.0 Cin OR TOM STArl euaee ,NOacal 7 W'vwqXm ❑ Nartac,aa . - Y. E] Ma ❑ q 27a DATE OP CEATj iJJ (Ala arr. Y,1 - r_ I ■ DATE BW , Y{ D v.. 288 TOW OF OEATH S .AS 7T0 DATE ram- 11bOW. VT1Vr1 270 'TNRE.OF OEATW K } fi. Y ffiE PRONOUNCED DEAD Aib Q!1'. Yi / 2A1 "Chou-NI-0 ,7EAD ftwI _ aTa ..IaaouttlTal Ceewreamtaa B JMi80ia}ataMC ; M ?2e One,eoarota~snmaon araan.saeamgro,.org aaa.on aam or.urar Perome.aYaarb lATM ane drblW rysUe~eMra 2a GD TOM= USE T GUNTFUIRMI-TOTHE DEATH? 3De ORGAN OWIISSUE DONATION BE EN COISWERED''~ 30b WAS ODC6HtT G9AhhTEO' ~ 13 VE8 O U UN04W 91 YES p NO ' 0 YES 240 31 IYAtlf ANOADDRCS_S6 IPMYSYJAN.G')a1NER8 VNYS1CUat OR COUNTY ATTORNEY. Twww"- - Dr. Kenneth Vettel: M.D. 2116 . Faidle Ave. #400, Grand Island, NE 68803 i 376 DATE FP.ED BY REQSrMA Ab Ay Yr, JUL 2 81997 BEfI ~ a>SO~ Anthony Carl Scholz Male July 21, 1997° -4, SU OP iwwrbU"metaCmW AM U~m g'nyAry 1 UI~TDAY &DA N dlfaRaT: - punctan, Nebraska M4 93 awn I DAYS 59 mm7wi September 19, 1903 505-48-7321 [f mm'.. FACWV aeafbRRkooAp +sa.af.aar~m6ah ❑ ERaRgaPSP ❑ a..aM,n Park Place Health Care' and Rehab Ctr. ❑ ODA 0 00.0-W V. 7. ORLODA710MOFOBATN ed FIBIDEODYLaRITB ea COWN OF WATH Grand Island Iva ® Na 0 Hall IF 7E ft ft C". WM ORU=MQ/ e6BTR3:TA210" m'i+Briyzi7coQN s.,N9oECarlA6s Nebrasim Hali Grand Island 610 N. Darr #211 688fl3 ® *-0 10 -p/.1rePa AeIM1EaAkgPel 11. ANC~TRYfeA•ePPIRt. MaaeMt.Oaalaat.l~I w 72 ® WARRED ❑ wi00Yll® f9. KWOFSPOUSE 19alrap" 010" - V fi+its 'American = r'1wD Clara Pollock 14L USMt OCCUPAYROM 4*W0fVftdM&9ft W TPR KODOF ROW-W t5. ®UDATRDN _ 01"gov dwasi mm &OOaCatI*t21 coamp qr or 5N O` Or Q ri tore t{ PATIGN-ft ME ow MIDGE LAST 17 Mon" PAST M IDLE 1AUDEN BLPNIAIE J Scholz Emma LeibTmdqut It WAG DECRABFD ENO W U$ tea ORORIMINT•NAME ~mau0.f -PYa tp+wraee4radaaAtaap - I .Clara Scholz m fooffiviff .m ORPFO.MO.tyTr diTOMM. STATE aM - 3757 W-Prairie Rd., Grand Island, Nebraska 68803. ~I Ma OFMIPUMTON MU DATE 21C. CMTRi1'ORCF01ATO W MME ®etaat ❑ Re,.ovM Jul 24. 1997 j u zm FtAaERAR frouE • CBPETERY OR CREMATORYLOCATION CrtYOR TOYAf STATE El c-- ❑ D- d I , Nebraska RS't ORRFD No C11YORTOWN .STATEZ"