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1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Gary Al Schnase 2. SEX Male 3. DATE OF DEATH (Mo, Day, Yr.) ' January 12, 2009 nj v 4: CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 1 , Hastings, Nebraska 5a. AGE -Last Birthday (Yrs.) 68 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) December 13, 1940 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506- 46-1002 Be. PLACE OF DEATH HOSPITAL: D Inpatient QTh 5 - ❑ Nursing Home/LTC ❑ Hospice Facility 0 ER/Outpatient ❑ Decedent's Home ❑ Dos ❑ Other (Specify) { 8b. FACILITY -NAME (If not institution, give street and number) St. Francis Medical Center Bc. CITY OR TOWN OF DEATH (Include Zip Code) r r Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE t x Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER S 932 S. Sycamore St. 9e. APT. NO 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS x) YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH §4 Married ❑ Never Married Cl Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife give maiden name. Esther Luebke 11. FATHER'S -NAME _ (First, Middle, Last, Suffix) Alfred Schnase 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Elda Scott 13. EVER IN U.S. ARMED FORCES? Give dales of service if yes. S - 14 'e 14a. INFORMANT -NAME Esther Schnase 14b, RELATIONSHIP TO DECEDENT Wife (Yes, no, oruX - 1 /15/61- 7/9/61 15. METHOD OF DISPOSITION ❑ Burial ❑Donation 16a. EMBALMER- SIGNATURE Not Embalmed 16b. LICENSE NO. - -- 16c. DATE (Mo., Day, Yr. ) January 12, 2009 } C Cremation ❑ Entombment LtRemoval ❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Crematory Grand Island, Nebraska 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City orTown, State) Apfel Funeral Home, 1123 West Second, Grand Island, NE. YY 1 �,3• 18. PART I. Enter the chain of events-diseases, injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE 17b. Zip Code 68801 �. � . .. INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE onset to death IMMEDIATE CAUSE (Final (a) Qrt4 if otn C Li mkt-V.- 1bl/tag as 1 lu r f 9t41 ur.x -. diseaseor condition resulting DUE TO, OR AS A CONSEQUENCE OF: I onset to death In death) Sequentially list conditions, If (b) any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I onset to death online. I Enter the UNDERLYING CAUSE (disease or injury that Initiated (c) theeventa resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: onset to death (d) 18. PART II. OTHER SIGNIFICANT CONDITIONS-Con it contributing t the ddegthh but not reeuiting in the under) ing cauy given in TIT � a al rx a W ti r o g4 s QP ell I�QG(A O 5 Wile" , r'w 4 ►sloast A /00 Sr.-r�5f5) 7 ut l dr1-- ' Wilke" 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES A NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death LI Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown it pregnant within the past year 21a. MANNER OF DEATH latural ❑ Homicide ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator C3 Passenger CI Pedestrian ❑Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑YESNO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? 4 ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN ' STATE ZIP CODE • 23a. DATE OF DEATH (Mo., Day, Yr.) i- /.? -o' x• 24a. DATE SIGNED (Mo., Day, Yr.) Ali 24b TIME OF DEATH m 1_ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) di. 0. 411 E!^ Z 6 24d. TIME PRONOUNCED DEAD' m 23b. DATE SIGNED (Mo., Day, Yr.) .... i -.,," 23c.TIME OF DEATH / i m 8 w 24e. On the basis of examination and/or investigation. in my opinion death occurred at 0 the time, date and place and due to the cause(s) stated. (Signature and Title ) • V t 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) • 25. DID TOBACCO USE CONTRIBUTETOTHE DEATH? YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES 4 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 4 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Richard Fruehling M.D. 2116 W. Faid ey; Grand Island, NE 68803 26a. REGISTRAR'S SIGNATURE i F xf . t r ' - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.). JAN 16 2009 DATE OF ISSUANCE JAN 2 0 2009 LINCOLN, NEBRASKA STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH.. D; H/(JMg4lV'SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA PAkT I0 MT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY, 1 Vz l,..1EE•CORQ'S „ _ 201209606 `$TANI Y COOPER 4 ., S cEPARTMENT OF HEAL.T*I;AAWD ' lMA/3 SERVICES. STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO ' ^ 0 ^ n CERTIFICATE OF DEATH U c c G HHS -61 11/03 (55061) - *( • • w