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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTI�.�t'Nl� M �� VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF 7HE ORIGINAL RECORb ON FILE WITH THE NEBRASl�'A`��RTM�'N1� QF �ALTH AND
<br />HUMAN SERVICES, VITAL RL�CORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 1a7T�fL.RE�,p l� �.: "� .�,'
<br />'_' R "�. d' � � , +,,�L.• r �t' .
<br />DATE OF ISSUANCE E , , . �:1 : �u�('�' ';�
<br />��I�l/I���A�9'�{�� � - .. . a. _.
<br />S7`i4NL�Y5.� ER �`"';''�
<br />� JUN 2 2 2012 2 Q�. 2(� 6 71 � Assr��°�anir�r ' :;
<br />DEPAR�A jEN�` OF NEALF�f AND �•r .�
<br />LINCOLN, NEBRASKA ---- =- HUM�f1�.S�l3�CES , r : � '
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ��; <z�� `. °� �, �;�'��.��'
<br />� GERTIFI ATE OF DEA H .�� ���L•
<br />1. DECEDENTSNANIE (Flrst, dlidrlle, Lest, BuHlx) � 2.8EJ( 3. D�lTEO tl TY� (A&o�,Bay;Yr.) ��
<br />Loretta Marie Schmidt Female Jung:19, 2412
<br />4. CITY AND 8TATE OR TERRITORY, OR FOREI6N COUNTRV OF BIRTH Sa. AGELask Blrthday Bb. UNDER 7 YEAR Bc. UN�ER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yre.) M08. DAYB HWR9 IOIIN9.
<br />Greeley County, Nebraska �
<br />7. 80CUU. SECURITY NUMBER
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<br />Bb. FACILITY-NAME pi not Irretidrtlon, glve etreet end numbe�
<br />Tabitha Nursing Home
<br />8c. CITY OR TO1NN OF DEATH (Inciude Lp Code►
<br />Lincoln 68510
<br />9a. RE8IDENC&STATE � 8b. COUNTY �
<br />Nelaraska Lancaster
<br />9d STREETAND NUMBER
<br />4720 Randolph Street
<br />10a MARITAL. STATUS AT'fmAE OF DEATH ❑ Merrled � Never Mai
<br />❑ x�ea. c�c saa�e�a � w�ao�a ❑ n���a p u��
<br />11. FATHER'SNAME (Fhst, AAlddle, LaeR BuNlt1
<br />92 June 10, 1920
<br />8a PU10E OF DEATH
<br />HOSPRAL: � InpaNa�R (�J�;� Nural� Home/LTC � Hoapice Facllity
<br />� ER/Outpatlant � � DecedeM'e Home
<br />❑ OOA � ❑Other(SP�Kll)_
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />Ba CITY OR TOYYN -
<br />Lincoln
<br />9e. APT. NO. 8L ZIP CODB Bg. INSIDE CITY LIMIT9
<br />68510 � res ❑ No
<br />10b. NAAAE OF SPOUSE (Flret, AAlddie, Last, SufPoc) H wHe, gNre maidan name.
<br />Charles Carl Schmidt
<br />1z AAOTHER'sNAME (Firat.
<br />Rubv Marie Kelle�
<br />13. EVER IN U.B. ARMED FORCES? 6Ne dates af eervlae B Y�. 14a. INFORMANT-NAd1E
<br />(Yes, No, orunk) Np �'ih8�Ott8 H8ZZ3fd
<br />18. METHOO OF DISPO$ITION 16a OMBALMER-91�NATURE
<br />❑B"'"' po°'°"°" Not Embalmed
<br />�Cramatlen �E�Rombmant
<br />�Remeval Qotharyepaoly) 98d, CEMETERY, CREMATORY OR OTHER LOCATION
<br />Lincoln CremaGon Service
<br />17a. FUNERAL HOAAE NAME AND NWLINO ADDRES9 (Street, Cfly or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Istand, Nebraska
<br />�a�on �
<br />@AMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />dlaeaae or conditlon resulUng a) 17 l Zh�! ihor
<br />I� death) � . �� � � �«
<br />DUE TO, OR AB A CONBEQUENCE OF:
<br />Sequentlaliy Ilet condlUo`re, H b)
<br />any, laeding to lhe caueu Ilated
<br />on Ilne a. OUE TO, OR A8 A CONSEQUENCE OF:
<br />Ente� Ne UNDERLYIN6 CAUSE �)
<br />(disease or InJury that Initleted
<br />tha eve�rts reaulU� In death) DUE TO, OR A.8 A CONBEQUENCE OF:
<br />LAST
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<br />14b. REUITIONSHIP TO DECEDENT
<br />18a DATE (Mo., �ay, Yr.)
<br />June 20. 20]
<br />STATE
<br />Nebraska
<br />�n. ziP coaa
<br />68801
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<br />� onseS to death
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<br />ionsetto death
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<br />ianaetto death
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<br />18. WA8 6AEDICAL EXAMWER
<br />OR CORONER CONTACTED7
<br />�A,rES ❑ No
<br />EAlddi& AAalden Sumame)
<br />18b. LICENBE NO.
<br />cmrrtoww
<br />Lincoln
<br />�s and example:
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<br />m.amuo� mre. a���y.
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<br />18. PART LL O7HER 9IONIFICANT CONDITION9-COnditlom u�rtributlng M the death 6ut rrot resulting In fhe underlyL�g cause ghren In PART 4
<br />Ny pe� �s�v�, t� p� l; pr de�va ,?"� 9.s
<br />20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR'
<br />ot prapneM wlthin past year �leturel ❑ Homkide ❑ DriverlOperator
<br />] PregnaM et Llme W death �Q Acciderrt ❑ Pendin8 ����Betton ❑ Paesenger
<br />❑NOt pregnent, but pregnant wlthln 42 deys of death ❑ 8uiclde ❑ Could rtot be determined ❑ Pedestrlan
<br />❑ Not preenerrt. 6ut pregnent 43 deye W 1 year before death ❑�e� (8P�«Y)
<br />QUnknown H pregneM wlthin the pastyear
<br />22e. DATE OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY
<br />m
<br />22d tNJURY AT WORK7 22e. DEBCRIBE HOW INJURY OCCURREO
<br />❑ YE8 ❑ NO
<br />22f. LOCATION OF INJURY - STREET & WUMBER, APT. NO.
<br />21a WA8 AN AUTpP3Y PERFORMED?
<br />❑ YE8 �IO
<br />27d WERE AUTOPBY FlNDWGS AVAILABLE
<br />TO COMPLETE CAUSE OF DPATH?
<br />❑ TE8 ❑ NO
<br />22a PLACE OF (NJURY-At home. ferm, straet, taetory, offlee bullding. co�retructlon sfte. eta. (9peeffyl
<br />cmrROww
<br />BTATE ZfP CODE
<br />23a DATE OF DEATH (Mo., Day, Yr.) ��� 24e. DATH SIONED (Ma., Day, Yr.) 24b. TIlAE OF DEATH
<br />� . �S�T r�� a
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<br />23b. DATE SIONED (Mo., Day, Yr.) 230. TIME OF DEATH �> O 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TINIE PRONOUNCED DEAD
<br />�o (O"a�b'�� ya3 f►� m � rc� � . m
<br />23d. To the beat of my Imowledga, death oawrted et tha time, date and pleee W Z 24e. On the 6asls of e:eminaUon enillor Imr�tlgatlon, In my opinton death oeeurred
<br />� and due to the (Slgnahue and TMI� � � � at the time. date end place aiM�due to the ca u s e(a) ete t e d ( 3 lg n a h v e an d T H Ie)
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<br />28. DID TOBACCO USE CONTWBUTE TO THE DEATH7 28a. HA9 OR6AN OR TISSUE DONATION BEEN CONSIDERED7 � 28b. WAS CONBENT 6RANTEDT �
<br />❑ YES �O � PROBABLY ❑ UNKNOWN ❑ YE9 O Not Applicabte Ii 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRE93 OF CERTIfIER (PHY8ICIAN, PHYSICIAN A8919TANT, CORONEIt'8 PHY81C1AN OR COUNTY ATTORNEI� (Type or�Print) -
<br />� SG G. �s�� ��/� o�bN I�. 20� sl- 5�;� If l,.� col�, M_° 6�sct�`
<br />��� 28a. RE613TRAR'8 ATURE � � -286. DATE FILBD BY REOISTRAR (Mo., Day, Yr.) ,
<br />P �� JUN 2 0 2012
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