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re 0 cc 0 w rc I- w z o. o . � • is E a 6 a' c 0 . 0 LOCAL FILE NUMBER 1. DECEDENT'S LEGAL NAME (First. Middle, Last, Suffix) JERRY SCHULTZ 5a AGE Last birthday (years) 18a INFORMANTS NAME 2004 REVISI 5b. UNDER 1 YEAR Months I Days !# RESIDENCESbeet and Number 375 EAST SCHULTZ ROAD 5c. UNDER 1 DAY Hours Minutes Al 8a RESIDBICEState 8b. RESIDENCE-County NF. HALL 6. DATE OF BIRTH 6!23!1947 9. MARITAL STATUS ATTIME OF DEATH 12Manied DNeverMeded ❑Widowed ❑Dtvaced ❑Married.butseparahed ❑unimown 11. FATHER'S NAME (First Middle, Last) ALLEN WAYNE SCHTTT,T7. 13. DECEDENT OF HISPANIC ORIGIN? (Check the boxthat best desalbeswlretlrerthedecedord is SPanishlHispardclLalma Check Mello' box din: decedent is not SpanisidHspanicA.alno) 55 No, notSpansM6spanirlLatno ❑ Yes, Mexican, Mexican American, Chicano ❑ Yes, Puerto Rican ❑ Yes, Cuban ❑ Yes, other Sp riadno (specify) .. 186. RELATIONSHIP TO DECEDENT 22. NAME AND COMPLETE A "RESS OF FUNERAr.Eren ALL FAITHS'_FUNERAL HOME 2929 S LOCUST GRAND ISLAND, NE 68801 STATE OF OKLAHOMA CERTIFICATE OF DEATH 201310083 STATE FILE NUMBER (Momaynr) 8c. RESIDENCE-City or Town DONTPHAN GRAND ISLAND CEMETERY 8/18/2010 2. SEX M 3. SOCIAL SECURITY NUMBER 508 -56 -0107 7. BIRTHPLACE ((fly and State or Foreign Country) GRAND ISLAND, NE Sd RESIDENCE -ZP Code 68839 10. SURVIVING SPOUSES NAME (If wife, give name prior to Ira marriage) LINELL SUE GULZOW 12. MOTHER'S NAME PRIOR TO FIRST MARRIAGE (First Midi. Las) PAULINE JOYE SNYDER 14. DECEDENT'S RACE (Check one or more races to indicate what the decedent considered 15. DECEDENTS EDUCATION (Check the bar that bestdesalbes the Ldnselfor herself to be) highest degree or level of school completed at the time of death. Wtdie ❑Sm grade or less &adcarAkican n ❑ American an or Naive ❑ -12th no dips Indi ❑ Asian Indian ❑ Chinese ❑ FPino ❑ Japanese ❑ Korean ❑ Other Asian (SpecTy) ❑ Pacific Islander (Sperry) ❑ Ohe<(Specih) 16. DECEDENT'S USUAL OCCUPATION (Indxsdetype of work done during most of working fife. DO NOT USE RETIRED. 117. KIND OF BUSINESS / INDUSTRY BUILDING CONTRACTOR (Name or the eraooed or pampa! trroe) CONSTRUCTION 18c. MAIUNG ADDRESS (Sheet and Number, City, State, Zip Code) 4. EVER IN US ARMED FORCES? ❑ Yes ® No 8e. RESIDENCE-Inside City Units? Yes FOND 8g. RESIDENCE-Apartment Number @Ftgh school graduate or GED completed ❑Bare college credd but no degree ❑ Associate degee (e.g. AA, AS) ['Bachelors degree (e.g. BA. M. BS) ❑Mantels degree (e.g. MEd, MA. MS MEng, NSW, MBA) Doctorate ctorate (e.g. PhD, Egli" or Proressional degree (eg.MD.JD) LINELL SCHULTZ WIFE 375 EAST ScEuL Z ROAN) T)ONTPHA 19. METHOD OFDISPOSMON: 20. PLACE OF DISPOSITION (Name of cemetery, crematory, other place) 21. LOCATION - City, Tam and Std Burial ❑ Cremation ❑ Donation ❑ Enewnb nest ® Removal from state ❑ Other (speedy) GRAND ISLAND, NE 23 . rECTO•rATILY MEMBER AS SUCH 24. EH ESTABUStg4ENT LICENSE # 2303 IF DEATH OCCURRED-IN A HOSPITAL: . Iii Inpatient ❑ Emergency RomnlOulpadent ❑ Dead on Arrival 26. FACILITY NAME (Ifni insfdution, give & number) SOUTHWESTERN REGIONAL MEDICAL CENTER 29. DATE OF DEATH 7/25/2010 (Mo/Day/Yr) CAUSE OF DEATH (See Instructions and examples) 34. PART I. Enter the chain of events- dseases, injuriesor conpteations -that directly caused t edeath. DONOTentartemdnal eventssuchansarancrest, respiratory arrest or venbicular fibrillation wrtlwtrtshowing the et y cause a ology .DONOTABBREVIATE. Enter only fines necessary - a r.S/ p . R./) /MI5 44 F aL:a;.4 p� D (or as a consequence of): b.144 1 11- 4 - jr - 4 1". 'o //jJ� 111 jrr�1; As) diva ` - . i 4- 0i-t4 Due to (or as aconseghence ol): IMMEDIATE CAUSE (Final disease or condition resulting in death Sequenta ly Tst coed Irons, Bany, leafing to the cause fisted on One a Enter the UNDERLYING CAUSE (dsease- . . c. Or injury that initialed the events resW6ng in death) LAST. 36. MANNER OF DEATH Natural ❑Hondcide ❑ Accident ❑ Suicide ❑ Pending Investigation . ❑Court not be detrained 39. DATE OF INJURY 40. TIME OF INJURY (MoiDayfYr) 44. LOCATION OF INJURY: Slate: Street & Number. 50. RE St NATU (l.ad) / k 30 TIME OF DEATH 2029 d. IF DEATH OCCURRED OTHER :HANINAHOSPITAL• - ❑ Hospice Fatty ❑ Nursing homelLong term care fealty ❑ Decedents home ❑ Other (away): 31. WAS MEDICAL EXAMINER CONTACTED? es 0 N 37. IF FEMALE: ❑ Not pregnantwhhin past year E1 Pregnant at time of death ❑ Not pregnant, btdpfegnantwitltin42daysofdeath ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 42. DESCRIBE HOW INJURY OCCURRED 41. PLACE OF INJURY (e.g., Decedent's home; construction site wooded area) City or Town 25. PLACE OF DEATH (Check only one see instructors) Due to (or as a consequence ot): 46. CERTIFIER (Check onlyone): 47. ATTENDING PHYSICIAN Physician inchergeof the paMnt'scare CI PhyNdanin attendance at tine of death only . To the best of myknowl death occurred atthe tree, date, and place, and due to the causes)and manner asstated. MEDICAL EXAMINER On Ire basis of exarrsradnn, and/or invesfigaton. in my opinion, death occurred at the time date and place, and due to the cause(s) and gfi stated. /'T , Signature of Certifier: / t��/M t6‹ 27. CITY OR TOWN STATE AND 21P CODE OF LOCATION OF DEATH TULSA OK 74133 - 32 WAS AN AUTOPSY PERFORMED? ❑Yes fNo Zip Code AnanmentNumbec 48. LICENSE NUMBER i L+. Lt. 30 f Appmmnatemfervat Onsetto death NAME ADDRESS AND EP CODE OF PERSON COMPLETING CAUSE OF DEATH (Item 34) UFO ,17 D tz- `1 g t 3 3 51: DATE AUG' • 1 e �v BY, REGISTRAR 20 ! 0 (Mo/DaymWr) 28. COUNTY OF DEATH TULSA 33. WEREAUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE 0 . DEATH? ❑Yes ) 35. PART IL Enter other sgnitcant conditions contribution to death but not resulting in the underlying cause given in PART I. DID TOBACCO USE CONTRIBUTE TO DEATH? es ❑No ❑ Probably ❑ Unknown 38. 43. INJURY AT WORK? ❑Yes 0 N 45. IF TRANSPORTATION INJURY SPECIFY: ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (specify) 49. DATE DEATH CERTIFIED - Ls G 7 , 2. a L +" (4o1Day/Yr) 52. DATE RECEIVED BY STATE REGISTRAR (Mo/Day/Yr)) VS 154 (1-04)