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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HF-AA AN' f~ AS, rr CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASM 'bENP~ EN•T. '0F,540ALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VIAL ORC)„
<br />DATE OF ISSUANCE • '
<br />STA&.EY S, COOPER,,
<br />05/10/2011 A§SlgrANT STATE RE'ISTRAR
<br />Dklll' PE OFHE4.0,l ANDY
<br />LINCOLN, NEBRASKA HUMA.~
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICliS: l' I 11 01509
<br />CERTIFICATE OF DEATH b `
<br />1. DECEDENTS-NAME (First, Middle, Last, Suffix)
<br />2. SEX
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />Clara Rose Scholz
<br />Female
<br />May 4, 2011
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Il
<br />ls. AGE -Last Birthday
<br />b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yrs.)
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />Hall County, Nebraska
<br />92
<br />July 30, 1918
<br />7. SOCIAL SECURITY NUMBER
<br />Be. PLACE OF DEATH
<br />507-16-4223
<br />HOSPITAL ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility
<br />Bb. FACILITY-NAME (if not institution, give street and number)
<br />❑ ER/Outpatlem ❑ Daeedenra Home
<br />P
<br />Wedgewood Care Center
<br />❑ DOA ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Sd. COUNTY OF DEATH
<br />o
<br />Grand Island 68803
<br />Hall
<br />I
<br />9a. RESIDENCE-STATE
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />Z
<br />Nebraska
<br />Hall
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />APT. NO.
<br />9f. ZIP CODE
<br />INSIDE CITY LIMITS
<br />800 Stoeger Ave
<br />68803
<br />[RYES NO
<br />F
<br />10a. MARITAL STATUS AT TIME OF DEATH[] Married ❑ Never Married
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown
<br />Anton Carl Scholz
<br />m
<br />11. FATHER'S-NAME (First, Middle, Last, Suf(Iz)
<br />12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />m
<br />Chris Pollock
<br />Lizzie Roth
<br />E
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />14a. INFORMANT-NAME
<br />14b. RELATIONSHIP TO DECEDENT
<br />8
<br />(Yes, No, or unit.) No
<br />Don Scholz
<br />Son
<br />,g
<br />15. METHOD OF DISPOSITION
<br />16a. EMBALMER-SIGNATURE
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />12
<br />® Burial ❑ Donation
<br />Matthew T. Myers
<br />1411
<br />May 9, 2011
<br />❑ Cremation ❑ Entombment
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br />❑ Removal ❑ Other (Specify)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />17b. Zip Code
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />68801
<br />CA SE OF DEATH See Instructions and exam les
<br />18. PART L Enter the chain of events, 4 1snases, Injuries, or complIcationsthat directly caused the death. DO NOT entaz terminal events such as cantlac arrest, ; APPROXIMATE INTERVAL
<br />respiratory arrest, or verdrimiar fibrillation without showing the etiology. DO NOT ABBREVIATE Enter only one muse on a line. Add additional Rose U necessary.
<br />IMMEDIATE CAUSE onset to death
<br />UOIEDIATE CAUSE (Final a) Colon Perforation ; 9 Days
<br />disease or condition resulting
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />Sequentially Rat condition% H b) Colon Cancer With Metastases To Liver
<br />any, leading to the muse listed
<br />on line a DUE TO, OR AS A CONSEQUENCE OF: ) onset to death
<br />Enter tits UNDERLYING CAUSE C)
<br />(disease or Injury that Initiated '
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST d)
<br />18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />I%
<br />0. IF FEMALE:
<br />21a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ Not pregnant within past year
<br />® Natural ❑ Homlelde
<br />❑ Driverlopeator
<br />❑ YES ® NO
<br />❑ Pregnant at time of death
<br />❑ Accident ❑ Pendhv Investigation
<br />❑ Passenger
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Suicide ❑ Could not be detemdned
<br />❑ Pedeetrlan
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />COMPLETE CAUSE OF DEATH?
<br />T
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Other (Spasm
<br />O
<br />❑ UnlvrewnIf pregnant within the past year
<br />YES NO
<br />m
<br />E
<br />n& DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />220. PLACE OF INJURY At home, fain, street, factory, office building, construction site, etc. (Specify)
<br />2
<br />22d. INJURY AT WORK?
<br />229. DESCRIBE HOW INJURY OCCURRED
<br />H
<br />❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APTAO. CITYIrOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />P May 4, 2011
<br />t A I
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />I
<br />23b. DATE SIGNED (MO, Day, Yr.)
<br />23c. TIME OF DEATH
<br />~
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />E
<br />Z May 4, 2011
<br />02:16 AM
<br />< a
<br />$ O To ore beet of my Imowladge, death occurred at the time. date and place
<br />$
<br />$
<br />8
<br />24e. On the bads of examination.&or lmesti9ation, in my opinion math occurred at
<br />and due to the cause(s) stated. (Signature and Title)
<br />~ $
<br />the tbae, date and place and due to the muse(s) stated. (Signature and Tale)
<br />Rebecca Steinke, MD
<br />;
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO Not Applicable H 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE ANB-051M F CERTIFIER (PHYSICIAN, HY 1 , coRONEITS PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Rebecca Steinke, MD, 2116 W Faldley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />-
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />-
<br />May 9, 2011
<br />
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