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STATE OF NEBRASKA 201308409
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ��
<br /> DATE OF ISSUANCE .. L"'"t)-"---
<br /> STANLEY S. COOPER
<br /> 09/04/2013 ASSISTANT STATE REGISTRAR
<br /> DEPARTMENT OF HEALTH AND
<br /> LINCOLN, NEBRASKA HUMAN SERVICES
<br /> STATE.OF NEBRASKA—DEPARTMENTOF..HEALTEI ANOHl1MAN:SERVICES FINANCEANO SUPPORT
<br /> .GERTIFICATE.OF DEATH: , 2 , - -• & Q
<br /> 1_DECEDENTS=NAME (First,, ,Middle,', ' Last,• Suffix), , '2.SEX S.DATEOF DEAR(MO-;Day,Yr.): ,
<br /> 'William 'Dean'. Schroer ' sale . August 22, 2013
<br /> 4:GtTY AND STATE OR TERRITORY,-OR FOREIGN'COUNTRY.OE BIRTH Sa.AGE-Last Birthday:.Sb UNDER I YEAR;':5c:UNDEA.,I DA1:, B:SATE OF BIRTH!(4c,,..;'
<br /> MO.;.Day;Yr)
<br /> '(Yrs.) ,.MOS. DAYS _HOURS.., MINS_:
<br /> Grand Island,. Nebraska. 74. June;21:,• 1,9,39•
<br /> •7.SOCIALSECURf1Y NUMBER I8a-PLACEOFDEATH -- - - _
<br /> 506-42-4341, HOSPITALS CI Inpatient QI}JEB t NursingHome/LTC O HospiceFacirrty
<br /> 81).FACILITY-NAME (If no1institution;,give.street:and number). QER/Ouryatient .. O:Decedem'sHOme
<br /> Tiffany Square...Care Center
<br /> -884,-sf::,...,9... . "5 .,,, and Island Q Oak ' Qoter(sv )
<br /> 8c.CITY OR TOWN OF,OEATH(InctudeZlp Code}: BdeCOUNTYOFDEATH,'
<br /> Grand Island 68801:::::: � Hall : ,
<br /> -
<br /> 9aRESlDENCESTATE -S1.COUMY 9c CITYORTOWN . ' •
<br /> •Nebraska Hall Grand Island
<br /> _ 9d.STREETANDflUMBER Se..APT;NO. -9F-ZIP CODE .9g:1NSIDE CITY LIMITS
<br /> 1'332 Sherman place 68803 x3 YES Q NO
<br /> POa.MARTTALSTATUSAT?.IMEOF DEATH 21 Married ❑Never Married 10b.NAME OF SPOUSE':(Eirst Middle,Last Sufftx)tfwife;'give maiden names
<br /> '_7itehrried,but separated '0Widowed. ❑Divorced CI Unknown- Sue- .H,olbert . .
<br /> .•11_FATHER'S-NAME' (First;' Middle, Last, Suffix):' -.12 MOTHER'S-NAME (First; '"Middle, Maiden Surname) ''
<br /> . . Louis': Schmer F:lonnie Becker ":'
<br /> 13:EVER IN U.S_ARMED'FORCES.?Give dates ofservicelfyes.'14a-1NFORMANTNAME'. 14b,RELATIONSHIP TO DECEDENT'
<br /> `'(Yes,naorunk.) No _ Sue ''SCh1IRer • Wife''•
<br /> in METHOD OFDISPOSMON ' .'.16a_EMBALMERSIGNATURE 160.LICENSENO- -180:DATE(Mo.,Day,Yr.I
<br /> ❑Burial ElDOnalbn Not'.-.Emba.lthed .. AnguSt '23,.20.13!;'. .
<br /> !Cremation 0 Entombment 16d.CEMETERY,-CREMATORYOR OTHER LOCATION. ,, CITY'(.TOWN STATE .
<br /> ❑Removal 0 Other:(Specify) - Central Nebraska' Cremation; Gibbon Nebraska . •
<br /> 17a FUNERALHOME NAME AND.MAILING-ADDRESS{Street,City orToivn.State)- 176_Zip Code
<br /> All. Faiths Funeral;;Rome,, 2929- S. Locust., Gr'a.nd'Island NE ' 68801 ,
<br /> _':'•18:'PART I.Enferthe ggainof'events-diseasealnj ones„or:computations-thedirebUgcausedthedeath,DO NOT enter.terminaleventssuch as cardiaaarrest; I APPROXIMATE INTERNAL - -
<br /> respiratoryarrest,orventrihular1iibdllationwithoutstiowingtheetioloy DOflOTABBREVIATT.Enter,nlyone.cau e:ona line.Add additional lineaifnecessary_ I
<br /> /27 y /a;0 /eere/ J'• yyyx+x;����_� I'
<br /> IMMmtAiECAUSE: ! "/p onset lb,dealh,
<br /> //
<br /> .:.NEDIATEcN�rod: �6 ��/.!tr ..../ f. lY4 f f� A
<br /> deeneartafedonlenAdn9 DUE TO,ORAA�SEOUENCEOF �-onset to death
<br /> '
<br /> � ) •
<br /> 5erfuenNNrynucond'rttarts,it: IN �.-,i!,',4/1,a'U-' _Q /l/!L:7.,. I y'e" �.- ---
<br /> 'aty,teadinglrtfrecauasliated' .DUETO,,OR ASACONSEOUENCEOF • ortsetto death:
<br /> ennlinea. ' , ,
<br /> k, •Bream erUNDETiLYiNGr'etiep '
<br /> s.' {dlseaaeortnju7thatinidated' ,(c) .. ' . i .
<br /> tirnawn[srawMhpmdmih) DUET°OR.ASA CONSEQUENCE,OF:, ;l onset todeath
<br /> :.18.PART II OTHER SIGNIFICANT CONDITIONS-COnditionscontdbuting to the death butnofresulting inthe:underlyingrouse given in PARTI, 19 WAS MEDICAL EXAMINER
<br /> / �L�l �n+ -- /�i, JCI�/�� T OR CORONEROACT£D? .
<br /> / ¢ , 72✓
<br /> '' r- cr,_1'7 ,-,2 00` OYES Ajt NO
<br /> '20,IFFEMALEc .21aEROF DEATH 219.IFTRANSPDRTATION:INJURY.21c.WAS ANAUTOPSYPERFORMED7
<br /> ❑Not pregnant within pant year Natural 0 HOrmcfde 'p Ddver/Operator
<br /> ., ❑YESO
<br /> O Pregnant at time of death. 0AecidentQ'PendingInvesligatlon . 'Punaenger '
<br /> ''PadesNan
<br /> .
<br /> O Not pregnant but A regnant within 42 des y odeeth ❑Suicide Q'Could notbe determined• 21d WERE AUTOPSYFINDINGSAVAILABLET
<br /> Q Other(Specity)'
<br /> O'Not'Pregnapt,butpregnent.43 daysto fyearbeloretleath COMPLETE:CRUSEOFDEATH? �;,
<br /> 0 Unknown ifpregnam within-the pastyear , OYES- QNO
<br /> 22a,DATE OFINJURY{MO•,tDay;YC) ' 122b TIME.OF INJURY '22c.PLACEOFINJURY-At home,farm,street,factoryoffice-buil ding;construction'sda,etc,(Seechy),' '
<br /> rtt
<br /> 22SINJURYATWORK7 ,22e:DESCRIBEHQW:INJURY OCCURRED '
<br /> .-. Q YES Q NO :,
<br /> 221 LOCATION OFINJURY-STREET&NUMBER AP.T.NO:-. CItY/TON@1 --- - SATE ZIP CODE'
<br /> -23a_DATE OF DEATH'(Mc Day,Yr) - - z 24a-DATESIGNED(Mn:,Day,Yr-) 24tr:TIMEOF DEATH;'
<br /> :.August. 22,2013: kaki m
<br /> :y :23b:DATESIGNED(Mo.,Day,Yr..) ' 23c.TIMEOFDFATH. i .24c,PRONOUNCED,OEAD(M..,Day,Yr;) 24d:TIMEPROWOUNCED DEAD
<br /> ki 2012 , 1.. <t rn.
<br /> > az: August 23,. 9:35'. a,m z
<br /> u'. 23d.To tbebestof mykr-'ad:-,dear••curr...et.he time:gateand:place 'u I24&On'the basis ol'examinabonaadlatimeshganon,in my opinion death occurred et
<br /> �: and due to th-•.� Slgna' eand.Title)7 ia8 I. thetime;dateand:placeandduetothecause(s):stated.:(Sfgnature'and'Trtle):7:
<br /> 25.DID:TOBA000'6SECONIRIBUTETOTHE DEATH? 26a:HAS,ORGAN'ORTISSUEE DDO'NATION-BEEN-CONSIDERED? ''26b.WAS.GONSENT GRANTED?,
<br /> . Q YES.•AO Q PROBABLY' Q UNKNOWN•' .: ,Q YES'.. • , , JeZ.NO ',', Not Applicable it2ea.is NO GI--YES ::10
<br /> 27:NAME,TITLEAND ADORESS-OFCERTIFIER'(PHYSICIAN,CORONER'S PHYSICIAN OR COUIfTYA1TTORNEY),(rypeor Print) ..
<br /> ,TanP A McDort,17 ':"M-D- 800: Artie et Grand•Island:•N.E".68803 '
<br /> 28a_REGISTRAR'S SIGNATURE . „ .. :28bi DATEFILED'BY REGISTRAR(Mo.,Day,Ye.): •
<br /> r ' , AUG':2.92013
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