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To Be CompletedNerlfled by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jeanette Clara Schmader 2. SEX Female ? 3. QA @'OF D TH (Mo.,Day,Yr.) December 1, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Dodge County, Nebraska 5a. AGE -Last Birthday (Yrs.) 80 6b. UNDER 1 YEAR 6c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) July 17, 1932 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -62 -6301 8a. PLACE OF DEATH ) ❑ Inpatient =mpg Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) 8b. FACILITY -NAME (If not Institution, give street and number) West Point Living Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) West Point 68788 - 8d. COUNTY OF DEATH Cuming 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Cuming 9c. CITY OR TOWN West Point 9d. STREET AND NUMBER 504 E. 13th Street 9e. APT. NO. 9f. ZIP CODE 68788 9g. INSIDE CITY LIMITS ® Ymi ❑ No 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Marred ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suabx) N wife. give maiden name. Harold Schmader 11. FATHER'S -NAME (First, Middle, Last, Suffix) John Yosten 12. MOTHER'S -NAME (First, Middle, Malden Surname) Bemadine Lodes 13. EVER IN U.S. ARMED FORCES? Give dates of service N Yes. (Yae, No, or uak.) No 14a. INFORMANT -NAME Harold Schmader 14b. RELATIONSHIP TO DECEDENT Spouse 16. METHOD OF DISPOSITION ® Bwt.t ❑Donation ['Cremation - ❑Entombment ['Removal ❑oM.r(apeafy) 16a. EMBALMER- StGNATUR ./� 16b. LICENSE NO. /0 fo - 16c. DATE (Mo., Day, Yr.) December 4, 2012 16d. CEMETERY, CR RY OR OTHER LO ATION CITY/TOWN STATE St. Michael's Cemetery West Point Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Stokely Funeral Home, 121 East Park, PO Box 55, West Point, Nebraska 17b. Zip Code 68788 �� To Be Completed by: CERTIFIER CAUSE OF DEATH (See instructions and examples) 18. PART i. Enter the shah d swat.. dlataw., Injuries, or oomplluMlonw MM dimody Gamed the death. 00 NOT sitar *mina( event. such u e.rdtao anent, APPROXIMATE INTERVAL respiratory *met, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Ent.r only one mum on a 110.. Add additional Iinee If necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final � r-- disease or condition resulting a) w 4A SR.aor 1 �Ar i' Z Yyxmir s disease) Mh 9 , g►o . WQ DUE TO, OR AS A CbNSEOUENCE OF: : onset to death Sequentially list conditions, d any, leading to the cause listed b) r.,..8 ; T .", • ook c .„,.,.., Wr Y.. %Y� r 1 f 1, on Ilia a. DUE 70, OR AS A CON0 UENCE OF: onset to heath Enter the UNDERLYING CAUSE c) (dismiss or inJury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART IL OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying caws givea In PART 1. 1 vii&- Net. Jn9bA hP A kjfQ V" COMM( 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? El YES NO 20. IF FEMALE: 11 Not pregnant within past year [�] Pregnant et time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑Unknown If pregnant within the past year 21a. MANNER OF DEATH Natural ❑ Homicide Accident ❑ Pending investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY Driver/Operator ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 216. WAS AN AUTOPSY PERFORMED? 0 YES NO 213. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES pi NO 225. 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? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYA'OWN STATE ZIP CODE b i tr _ EJo 23a. DATE OF DEATH (Mb., Day, Yr.) t 2 - t I'L- >. g g t 8 a a r a. y < T o 8 W = 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, Yr.) 12. -H - fl 23c. TIME OF DEATH ii 0.'! «m 24e. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD Pe V 23d. the bast of my knowledge, death occurred et tat tire, date and place. o end dw so the eawe(s) stat (Sig nature and Tide) 24.. On tea bash of examinatio n andlor investigation, in my Opinion death occurred M the t ee , date and place and due to the cause(s) stated. (Signature and Tide) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY 14 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ,x NO 28b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Anita Stoke,6 PA, 306 W. 2nd S.tieeet, Tilden, NE 68781 P 4 28a. REGISTRARS SIGNATURE j GCS, 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) DEC o 5 2atz DATE OF ISSUANCE DEC 0 5 2012 LINCOLN, NEBRASKA 2 01308695 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMEN7"OF HEALt D� i-1 fERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA PAIRY4NE,N ,HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO V UAL RECORDS ,T,WLEY S CQOPER. -- • ' e4SSISTA T S ,e 4STRAR '.. SEP JRTME!IT 44 - H /fNQ wymAN SF`i2VICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER ES S' CERTIFICATE OF DEATH .. . , I t9.4.