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STATE OF NEBRASKA
<br />WHEN TH/S COPY CARA/ES THE RAISED SEAL OF THE NEBRASKA HEALTHAN!?flllA�L4�l1 _ RVICES
<br />SYSTEM, IT CERTIFlES THE BELOW TO BEA TRUE COPY OF THE OR/G/NAL �? Fi{Q70 •¢ � 1A(ITH s
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<br />THE NEBRASKA HEALTH AND HUMAN SERV/CES SYSTEM, VITAL STATiS b1J��1'IS '
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,`� C,,, �-� �b �,�p'} � r,;: ��
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<br />DATE OF ISSUANCE ° ' . , ��
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<br />LINCOLN, NEBRASKA H�A�T,I{AND�IUIMAN:SER4/I,CE� �'
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<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH ANO HUMAN SERVICES FI A�� SIJP�
<br />CERTIFICATE OF DEATH " �
<br />��Y 1. DECEDENT'8-NAME (Firat, Mlddle, Laet, 9uflix) 2. SEX 3. DATE OF DEATH (Ma, Dey, Yr.)
<br />f���' Michael James Schneider Male June 23, 2008
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<br />��; }; 4. CITY AND STATE OR TEHRITORY, OR FOREION COUNTRY OF BIRTH ba. AOE•Last Birthday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIHTH (Mo., Dey, Yr.)
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<br />�"�' Hastings, Nebraska �YfB•� 54 MOS. DAYS HOURS MiNS. October 22, 1953
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<br />3 " � 7. BOCNL SECURITY NUMBER He. PLACE OF DEATH �
<br />;-�' � 507-72-6362
<br />i '� N9�ELTA6: O lnpatlent QTFI� O NureingHomelLTC ❑ Hospice Facility
<br />��'' 8b. FACILITY-NAME (If not Inatltution, give street end number)
<br />j;sf��`� ❑ ER/Oulpedent �I Decedent's Home
<br />Home: 405 Rosewood Circle
<br />Y l' ❑ uy1 ❑ othai(st�ecfly)
<br />�� +", 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />j� t �, Grand Island 68803 Hall.
<br />p � 9aRESIDENCE-STATE 8b.00UNTY Bc.CITYOpTOWN
<br />;"=�;i Nebraska Hall Grand Island
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<br />8d STREETAND NUMBER Be. APT. NO 8f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />{�,. �;? 405 Rosewood Circle 68803 �I YE8 o No
<br />��p' 10a. MARITAL STATUS ATTIME OF DEATH [�Married ❑ Never Marded 10b. NAME OF SPOUSE (Flrat, Middle, Laet, SufllxJ If wife, giva maidan neme.
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<br />� ❑ Martled, but sepereted C7 W�dowed ❑ Dtvorced ❑ Unknown C indy McGahaa
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<br />t ° 11. FATHER'S-NAME (Firet, Mlddie, Laet, Suf1lz) 12. MOTHER'S-NAME (Firat, Mlddle, Maiden Surnqme)
<br />'��� James Schneider Theresa Rem e
<br />a ►$ , P
<br />�,- . 13 EVER IN U.S. ARMED FORCE94 Olve datea of service If yes. 14a.INFORMANT NAME 14b. RELATIONSHIP TO DECEDENT
<br />,� � 1/20/1978 Cindy Schneider Wife
<br />�,�� ; 1b. METHOD OF DISPOSITION 18a. ER-SIpNA RE 18b. LICENSE N0. 18c. �ATE (Mo., Oay, Yr. )
<br />i��� �Buriel Ooonetlon� . ,�{,� � Jt1IIe 26� 2��$
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<br />;�H�� ❑Cremetlon ❑Entom6ment 18d.CEMET ,CREMATORYORO RLOCATION CITY/TOWN STATE
<br />� ❑Remmel ❑rnne��sPa�ny� Grand Island Cemetery, Grand Ysland, Nebraska
<br />� �:
<br />17aFUNERALHOMENAMEANDMAILINGADDRESS (Siree6CityarTown,State) 176.2IpCode
<br />�$�; Apfel Funeral Home, 1123 West Second, Grand Island, NE 68801
<br />t i t �. {�t �rt«:,s€��.� �!� ;,��4. ;.`...�.� v �. � ,�� ;:�;Z.�'�T ,,E�s��` � R17��111 �$� '�.��'"G x �"-, r a t � .:; `+ ��`u:�
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<br />�� 18. PART I. Enter tfie ohefn ai avente•-diaeasea, Injuries, or complicatlona--that directly ceuaed the death. DO NOT enter terminei eventa sucfi ae cerdiec enest, � APPROXIMATE INTERVAL
<br />� x -' resplratory anest, or venhicular ffbrlllatlon wtthout ahowNg the eUology. DO NOT ABBREVIATE. Enter oniy one cause on a Iine. Add addidonal Itnes N necessery. �
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<br />�^��'k; IMMEDIATECAUSE � onaettodeath
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<br />,'�; ���t� c� L 6 t ' � Y�
<br />�; m�O����B DUETO,ORA9ACONSEDUENCEOF: i onsettodeeth
<br />��%�;'::; Indeath) �
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<br />i Se9�e�de�tyltetcondltlone�H @) � I
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<br />�-� �'��� DUETO,ORASACONSEOUENCEOF: I onaettodeaffi
<br />„�' onMea
<br />�'��i� &derNteIWDERLYW�CAl138 I
<br />:1.."'F?� (dlseaseorinJurythatinitleled ��� I
<br />° ;�,r� ������) DUETO,OAA3ACON3E�UENCEOF: i onsettodeath
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<br />� 18. PART II.OTNER SI(iNIFICANT CONp1170NS-Conditione contrlbuUng io the death but not reaulUng In the undeAying ceuae glven (n PART I. 19. WA3 MEDIGAL EJfAMINER
<br />"''r�a i
<br />��2;:�� OR CORONER CONTACT8D7
<br />�� ��9�1 .
<br />r�s
<br />❑ YES , NO
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<br />�? 20.IFFEMALE: 21e.M 21b.IFTRANSPORTATIONINJURY 21c.WA3ANAUTOP3YPERFORMEDT
<br />! ❑ Not pregnent vrtthin past yeaz yynetural ❑ Homlclde ❑ DrivedOperaror
<br />❑Passenger ❑ YES �10
<br />� ❑ Pregnent at time of death O AccideMO PerMing InvesUgaUon T
<br />` �" 0 Notpregnent,butpregnantwiihin42daysofdeaN ❑Pedestdan p�dWEREAUTOPSYFINDINaSAVAILABLETO
<br />�,�' � ❑ 3uicide ❑ Coutd not be detertnirred � p�ryer (SpecHy)
<br /><�
<br />� ❑ Not pregnent, but prepnarrt 43 deys to 1 year bePore death COMPLETE CAUSE OF DEATH7
<br />s�, 'sq ❑ Unknown it pregnant withfn the pastyear ❑ YES 0 NO
<br />sJi� ;;�; 22a. DATE OF INJURY (Mo., Dey, Yr.) 22b. TIME OF INJURY � 22c. PLACE OF INJURY-At hame, farm, street, factory, ofitce building, conaWCBon aite, etc. (Speclty) . � _
<br />� ;,. m -
<br />'\;�": 92d.INJURYATWORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />�';+�' ❑ YES ❑ NO
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<br />i 22f. LOCATION OF INJURY - STREET & NUMBER, APT. N0. CTfY/fOWN SRUE ZIP CODE
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<br />j � 23a. DATE OF DEATH (Mo., Day, Yc) 24a. DATE SIONED (Mo., pay, Yr.) 24b.TIME OF DEATH
<br />° �' June 23, 2008 ��� m
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<br />�➢� 23b. DATE 310 ED (Mo., DegYr.) 23c.TIME OF DEATH ��� 24c. PpONOUNCED DEAD (Mo., Day,Yc) 24d.TIME PRONOUNCED DEAD
<br />M1 '
<br />} �t -iN' 6� 2: 21 . m a m a� m
<br />�f�j � �0 �
<br />,.� � 23d. To tfie best of my knowl e, death occurted et the time, dete and ptace � u� �� 24e. On the baeis ot exeminatlon andlor irnes8gadon, In my opinion death occurred et
<br />�s !� e and due to the caus � at ted ,{51 ure end )♦ .� �$ the tlme, dats end pleca end due to tha ceuse(s) eteted. (Signature antl TWe )♦
<br />t dP'iF�� ' � �
<br />���'��s;G; $ �
<br />�": 26. DIDTOBACCO USE CONTRIBUTET07}IEDEATH? 28a. HAS OR�AN ORTISSUE DONATION BEEN CONSIDERED? 28b. WA3 CON9ENT ORANTED7
<br />�`i:
<br />p,` ❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES �Q Not Appllcable 1128a le NO ❑ YES NO
<br />: 27.NAME,TITLE NDADDRESSOFCERTIFlER (PHYSICUW,CORONER'SPHYSICIANORCOUNTYATTORNEI� (TypeorPrlN)
<br />�` David Colan M.D. 729 N. Custer Ave., Grand Island, NE 68803
<br />28e. RE�tSTRAR'S SIGNATURE � 28b. DATE FILED BY PEti18TRAR (Mo., Day, Yr.)
<br />, ,)UL � 2008
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