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To be completed by: CERTIFIER 1 1 To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Donald John Schultz 2. SEX i t Male �',`�ti f8, D TE'OF„♦ !'ATH (Mo., Day, Yr.) v ccjanuicify,20, 2015 -; - 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cairo, Nebraska 5a. AGE - Last Birthday (Yrs.) 91 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) September 28, 1923 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506-46 -1830 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8a. PLACE OF DEATH HOSPITAL ® Inpatient 9THER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 4874 North Monitor Road re. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS I ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Darlene A Wilhelmi 11. FATHER'S -NAME (First, Middle, Last, Suffix) Peter Schultz 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Emma Vick 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Darlene Schultz 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) January 24, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Berwick Cemetery Cairo Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events - -diseases, injuries, or complications -that directly caused the death. DO NOT entertenninal events such as cardiac arrest, r APPROXIMATE 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: IMMEDIATE CAUSE (Final a) Sepsis With Chronic Right Leg Ulcer disease or condition resulting onset to death 5 Days in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b)Acute Renal Failure 1 any, leading to the cause listed I i on line a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death Enter the UNDERLYING CAUSE c) 1 (disease or injury that initiated I the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) I 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 0 N 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 49 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 ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE W r o u i 23a. DATE OF DEATH (Mo., Day, Yr.) January 20, 2015 a s $ = r c " Z . p 12 g S 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 22 2015 23c. TIME OF DEATH I 03:05 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD cli 0 3d. To the best of my knowledge, death occurred at the time, date and place V a n d due to the cause(s) stated. (Signature and Title) s Richard Fruehling, MD 24e. On INC basis of examination and /or Investigation, in my opinion death occurred at the time, dab and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 128a. REGISTRAR'S SIGNATURE A - 'O � 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 27, 2015 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT4141AN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR4.SKA pE?f4 eINT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR FtE Vt s. , t DATE OF ISSUANCE 01/30/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA STANLEY S. CO PEk ""Z�EGIST V4R,, DE.Pt4R7 1 / ® A4LTf# A'NrV ,= HC/MAN SERVICES { • STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES " � " i � � r• � 4 2 ' CERTIFICATE OF DEATH ' j ',.,; r ' • .... 201501028 15 00465