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1se 1A WHEN TICS COPY CARRIES TIE: RAISED SEAL OF THE NEBRASKA HEALTH CES SYSTEM R CERTF ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL @. THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI� THE LEGAL DEPOSITORY FOR VITAL RECORDS T" a DATE OF ISSUANCE 20010019 SEP 2 91999 STATE ASSt$TiIFiVT. REG /STIgAf LINCOLN, NEBRASKA HEALTH AND HUMA m s.?RVICPS s*sTd N STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIM MANCiXH1 SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH 1. DECEDENT - NAME FIRST MIDDLE UST 2. SEX IQ (I Male September 14, 1999 4. CITY AND STATE OF BIRTH (d not in USA.. name cocintryl Sa. AGE • Last Birthday UNDER 1 YEAR DA S. DATE OF BIRTH (MorNi Day Year1 M m Hall County, Nebraska (Yrs.) 66 March 9, 1933 7. SOCIAL SECURTIY NUMBER ft. PLACE OF DEATH = n Z = Bb. FACILITY • Nams Ill nor ristitulan, give sheet and number) o ❑ DOA ❑ Other(Spvedvi 8c, CITY. TOWN OR LOCATION OF DEATH m N. COUNTY OF DEATH Kearney VW :21 N. ❑ Buffalo a. RESIDENCE - STATE lib COUNTY Cl) cn ON 9e. INSIDE CITY LIMITS 7� � N 54710 175 R ad yes 11 NO ia C � 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE (M ee9. gwemaiden name) e1allSpecify IWhite (Specify) German NEVER DIVORCED DMARRIED Evelyn Crouch 14a. USUAL OCCUPATION )Give kmdot work don) ourtirIg most -r, m Of nrodring lib. even d r-armer Agriculture I Elementary or rondary 10.12) Cole" 11 .4 or 5.1 the lime. data and place and due to tlb caueets) stated /�vA! S e and Title 0- • t / M z O O 30.b WAS CONSENT GRANTED? ❑ YES �NO ❑ UNKNOWN ❑ YES ® NO ❑ YES © NO 31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pdntj - - - CyN,tIA mr -n O '!! O O o ( o p ` O co 71 o r M ry 0 f- + CD co co v, rn N WHEN TICS COPY CARRIES TIE: RAISED SEAL OF THE NEBRASKA HEALTH CES SYSTEM R CERTF ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL @. THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI� THE LEGAL DEPOSITORY FOR VITAL RECORDS T" a DATE OF ISSUANCE 20010019 SEP 2 91999 STATE ASSt$TiIFiVT. REG /STIgAf LINCOLN, NEBRASKA HEALTH AND HUMA m s.?RVICPS s*sTd N STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVIM MANCiXH1 SUPPORT VITAL STATISTICS CERTIFICATE OF DEATH 1. DECEDENT - NAME FIRST MIDDLE UST 2. SEX 3. DATE OF DEATH (Mom Day. Ysar1 Robert Lee Schutt Male September 14, 1999 4. CITY AND STATE OF BIRTH (d not in USA.. name cocintryl Sa. AGE • Last Birthday UNDER 1 YEAR DA S. DATE OF BIRTH (MorNi Day Year1 sb.MOS 1 DAYS Sc. H 7�� Hall County, Nebraska (Yrs.) 66 March 9, 1933 7. SOCIAL SECURTIY NUMBER ft. PLACE OF DEATH 508-46-7035 HOSPITAL: ® Inpatient OTHER: ❑ Nursing Home ❑ ER Ou"Ident ❑ Residence Bb. FACILITY • Nams Ill nor ristitulan, give sheet and number) Good Samaritan Hospital ❑ DOA ❑ Other(Spvedvi 8c, CITY. TOWN OR LOCATION OF DEATH .8d. INSIDE CITY LIMITS N. COUNTY OF DEATH Kearney VW :21 N. ❑ Buffalo a. RESIDENCE - STATE lib COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Code) 9e. INSIDE CITY LIMITS Nebraska Buffalo Shelton 54710 175 R ad yes 11 NO ia 10. RACE - (e.g.. White. Black. American Indian. 11. ANCESTRY le.g.. Italian. Mexican. German, MI 12. ® MARRIED ❑ WIDOWED 13. NAME OF SPOUSE (M ee9. gwemaiden name) e1allSpecify IWhite (Specify) German NEVER DIVORCED DMARRIED Evelyn Crouch 14a. USUAL OCCUPATION )Give kmdot work don) ourtirIg most tab. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade complelW) Of nrodring lib. even d r-armer Agriculture I Elementary or rondary 10.12) Cole" 11 .4 or 5.1 .+o� mwulc �..or I �r. m -in rn.o� Miwlc -- rnaunnraac Roy Schutt I Loretta Cox T tE, WAS DECEASED EVER IN U.S. ARMED FORCES? Korean 19a. INFORMANT •NAME (Y.a�oeors k., 17%17%x53 dates 6/8/55 Evelyn Schutt 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIPI 54710 175 Road Shelton, Nebraska 68876 20. EM R - SI ATURE 8 LICENSE NO 21 a. METHOD OF DISPOSITION 21b. DATE _ 21d. CEMETERY OR CREMATOR', NAME Burial 11 Removal 9/17/99 Kearney Cemetery -22s. FUN AL H E - NAM pfel Funeral. Home ❑O1B1,,�„n ❑Doi1w 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Kearney, .Nebraska M 101 M. FUNERAL HOME ADDRESS (ST BEET OF R.F.O. NO_ CITY OR TOWN STATE. ZIP) Box 126 Wood River, Nebraska 68883 e i 1 I Ielr r en VNLr Lm i,-= - Unit rvn lal. lot, Rry tcp mrmva� oerween unsay a- Ream I 23. IMMEDIATE CAUSE p Vd PART al 25. WAS CASE REFERRED TO MEDICAL EX/'.MINER OR CORONER? yea 0 No e DuE TO, OR AS A C 28c. HOUR OF INJURY \ Accident R Undetermined M 101 Suicide [] Pending Homicide Inves"atan DUE TO. OR A C 2&. PLAB E QFi CRY /!1t Mlnp, farm, street. factory tiff bwld SPad4 289. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 27a. DATE OF DEATP JW... y. Yr./ 28a. DATE SIGNED (MO. Day. Yr) e i 1 I Ielr r en VNLr Lm i,-= - Unit rvn lal. lot, Rry tcp mrmva� oerween unsay a- Ream I OTHER SIGNIFICANT CONDITIONS - Conditions Contribting to tro death but not related PART P iIR i (� PREGNANCY N(Ages I Interval bett/witieenn onset and death 2a AUTOPSY Yes No 25. WAS CASE REFERRED TO MEDICAL EX/'.MINER OR CORONER? yea 0 No I kaervaf DMwaen o1HM ant death 328. REGISTRAR fM W BY REGISTRAR /A of Day Yr./ I OTHER SIGNIFICANT CONDITIONS - Conditions Contribting to tro death but not related PART P iIR i (� PREGNANCY N(Ages III IF FEMALE. WAS THERE A M THE PAST 3 MONTHS? 10 -541 Yes No 2a AUTOPSY Yes No 25. WAS CASE REFERRED TO MEDICAL EX/'.MINER OR CORONER? yea 0 No 28x. 28b. DATE OF INJURY (Ma.. Day. Yr/ 28c. HOUR OF INJURY 26d. DESCRIBE MOW INJURY OCCURRED Accident R Undetermined M Suicide [] Pending Homicide Inves"atan 280. INJURY AT WORK Yes ❑ -E] 2&. PLAB E QFi CRY /!1t Mlnp, farm, street. factory tiff bwld SPad4 289. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE 27a. DATE OF DEATP JW... y. Yr./ 28a. DATE SIGNED (MO. Day. Yr) 28b. TIME OF DEATH S z Al M 27b. DATE SIGNED (MO. Day. Yr) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD (Mo.. Day. Yrl M. PRONOUNCED DEAD /Abal $g 12.15 P a S - M 27d. 7o IM best of my knowledge. death occ mod 81tt ame. date and place to Me 280. On the basis d examination and,or investigation, in my opinion death occurred at causets) stated. a the lime. data and place and due to tlb caueets) stated /�vA! S e and Title 0- • t / ! re and Title 29, DID TOBACCO USE CONTRIBUTE TO Tj DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES �NO ❑ UNKNOWN ❑ YES ® NO ❑ YES © NO 31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pdntj - - - CyN,tIA mr 328. REGISTRAR fM W BY REGISTRAR /A of Day Yr./