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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Betty Jean Schmidt 2. SEX, ' ... Female 3. DATE OF DEATH (Mo., Day, Yr.) M arch 31, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Aurora, Nebraska 5a. AGE - Last Birthday (Yrs.) 73 5b. UNDER 1 YEAR 5c. UNDER 1 DAY ' 6. DATE OF BIRTH (Mo., Day, Yr.) June 18, 1941 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -52 -3683 8b. FACILITY -NAME (If not Institution, give street and number) 2308 West 5th Street 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code). - Grand Island 68801 Bd. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2308 West 5th Street 19e. APT. NO. 8f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® 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 Charles Schmidt 11. FATHER'S -NAME (First, Middle, Last, Suffix) Rueben E Ott 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Hazel L Ryder 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Charles Schmidt 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.) April 6, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Concordia Cemetery Prosser 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 (See instructions and examples) 18. PART I. Enter the chain of events. diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL To be completed by: CERTIFIER 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) Respiratory Failure disease cr.or,dition resulting onset to death Immediate In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) Cardiopulmonary Arrest Immediate any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. Deceased Had Suffered A Myocardial Infarction 9 Months Prior And Had A Blood Clot 8 Months Prior. Deceased Also Had Acromegaly 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: ® Not pregnant within past year 0 Pregnant at 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 ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21 d. 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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE . W d E 6 r z 23a. DATE OF DEATH (Mo., Day, Yr.) k S z 1 E Y E a,a Z ' w O g Q u a 12 o u 24a. DATE SIGNED (Mo., Day, Yr.) April 1, 2015 24b. TIME OF DEATH Approx. 02:30 AM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) March 31, 2015 24d. TIME PRONOUNCED DEAD 03:40 AM ' 6 O 23d. To the best of my knowledge, death occurred at the time, date and place e c and due to the cause(s) stated. (Signature and Title) ii 2y On the basis of examination and/or investig tion, in my opinion death occurred at the time, date and place and due to the cau e(s) stated. (Signature and Title) Jon Hendricks, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jon Hendricks, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 28a. REGISTRAR'S SIGNATURE do 1 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 3, 2015 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASeiretAINTIoNNT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOP 1T4fRECORD5,' .J'SY,4NL.EY S. CQC?PER AtS.5IST T, TATE REGISTRAR DYPAR T HEALTH AND HUMAN ILS STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEkVICE, CERTIFICATE OF DEATH DATE OF ISSUANCE 04/06/2015 LINCOLN, NEBRASKA 201503066 15 01965