|
- STATE OF NEBRASKA
<br /> r WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HL%CTH AND HUMAN SERVICES,IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA L EPARTh?ENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br /> DATE OF ISSUANCE ' '- U'
<br /> 12/31/2014 201505747 STANLEY S. CQQPER
<br /> ASSISTANT STATE REGISTRAR
<br /> DEPARTMENT Ot HEALTH AND
<br /> LINCOLN, NEBRASKA HUMAN SERVICES
<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES 14 06743
<br /> CERTIFICATE OF DEATH
<br /> --
<br /> 1.DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.SEX ' 3.DATE OF DEATH(Mo.,Day,Yr.)
<br /> Barry Donald Schultz Male December 25,2014
<br /> 4.CITY AND STATE OR TERRITORY,OR FOREIGN COUNTRY OF BIRTH 5a.AGE-Last Birthday 5b.UNDER 1 YEAR 5c.UNDER 1 DAY 6.DATE OF BIRTH(Mo.,Day,Yr.)
<br /> (Yrs.) MOS. DAYS HOURS ` MINS.
<br /> Grand Island, Nebraska 61 October 12, 1953
<br /> 7.SOCIAL SECURITY NUMBER 8a.PLACE OF DEATH
<br /> 506-68-1458 HOSPITAL ®Inpatient OTHER ❑Nursing Home/LTC ❑Hospice Facility
<br /> 8b.FACILITY-NAME(If not Institution,give street and number) ❑ER/Outpatient ❑Decedent's Home
<br /> rt
<br /> o CHI Health St. Francis ❑DOA ❑Other(Specify)
<br /> U
<br /> ILI 8c.CITY OR TOWN OF DEATH(Include Zip Code) 8d.COUNTY OF DEATH
<br /> cc
<br /> c Grand Island 68803 Hall
<br /> Q 9a.RESIDENCE-STATE 9b.COUNTY 9c.CITY OR TOWN
<br /> to Nebraska Hall Grand Island
<br /> LL9d.STREET AND NUMBER e.APT.NO. 9f.ZIP CODE 9g.INSIDE CITY LIMITS
<br /> T 4252 Vermont Avenue r 68803 ® YES ❑ NO
<br /> '0
<br /> '0 10a.MARITAL STATUS AT TIME OF DEATH®Married ❑Never Married 10b.NAME OF SPOUSE(First, Middle, Last, Suffix)If wife,give maiden name
<br /> w
<br /> C ❑Married,but separated ❑Widowed ❑Divorced ❑Unknown Debra L Axtell
<br /> Z 11.FATHER'S-NAME (First, Middle, Last, Suffix) 12.MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> 4.)
<br /> ▪ Donald J Schultz Marion I Dankert
<br /> o.E 13.EVER IN U.S.ARMED FORCES? Give dates of service if Yes. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT
<br /> u (Yes,No,or Unk.)No Debra L Schultz Spouse
<br /> 2 15.METHOD OF DISPOSITION 16a.EMBALMER-SIGNATURE 16b.LICENSE NO. 16c.DATE(Mo.,Day,Yr.)
<br /> F2 ®Burial ❑Donation
<br /> Tracey Dietz 1328 December 30,2014
<br /> ❑Cremation 0 Entombment 16d.CEMETERY,CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br /> ❑Removal ❑Other(Specify)
<br /> Berwick Cemetery Cairo Nebraska
<br /> 17a.FUNERAL HOME NAME AND MAILING ADDRESS(Street,City or Town,State) 17b.Zip Code
<br /> Apfel Funeral Home, 1123 W.2nd,Grand Island,Nebraska 68801
<br /> CAUSE OF DEATH(See instructions and examples)
<br /> 13.PART I.Enter the chain of events-diseases,injuries,or complications-that directly caused the death.DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratory arrest,or ventricular fibrillation without showing the etiology.DO NOT ABBREVIATE.Enter only one cause on a line.Add additional lines if necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE(Final a)Multi system Organ Failure Days
<br /> _ , disease or condition resulting
<br /> in death) DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions,if b)Metastatic Renal Cell Cancer Months
<br /> any,leading to the cause listed
<br /> on line a. DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE c)
<br /> (disease or Injury that initiated
<br /> the events resulting in death) DUE TO,OR AS A CONSEQUENCE OF: I onset to death
<br /> LAST d)
<br /> 18.PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19.WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> re W I 1:1 YES ®NO
<br /> LL 20.IF FEMALE: 21a.MANNER OF DEATH 21b.IF TRANSPORTATION INJURYI21c.WAS AN AUTOPSY PERFORMED?
<br /> ❑Not pregnant within past year ®Natural ❑Homicide ❑Driver/Operator ❑ YES ® NO
<br /> W Pregnant at time of death ❑Passenger
<br /> ✓ ❑ ❑Accident ❑Pending Investigation
<br /> ❑Not pregnant,but pregnant within 42 days of death ❑Pedestrian 21 d.WERE AUTOPSY FINDINGS AVAILABLE
<br /> a ❑Suicide ❑could not be determined TO COMPLETE CAUSE OF DEATH?
<br /> ,0 ❑Not pregnant,but pregnant 43 days to 1 year before death ❑Other(Specify)
<br /> t ❑Unknown If pregnant within the past year _ ❑ YES ❑ NO
<br /> E• 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)
<br /> E
<br /> 0
<br /> v
<br /> 2 22d.INJURY AT WORK? 22e.DESCRIBE HOW INJURY OCCURRED
<br /> 0
<br /> F' ❑YES ❑NO
<br /> 22f.LOCATION OF INJURY-STREET&NUMBER,APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 23a.DATE OF DEATH(Mo.,Day,Yr.) 24a.DATE SIGNED(Mo.,Day,Yr.) 24b.TIME OF DEATH
<br /> .r 5 December 25,2014 -
<br /> i F 23b.DATE SIGNED(Mo.,Day,Yr.) 23c.TIME OF DEATH 24c.PRONOUNCED DEAD(Mo.,Day,Yr.)24d.TIME PRONOUNCED DEAD
<br /> E°ul December 26,2014 I 12:22 AM
<br /> y O Z
<br /> O 3d.To the best of my knowledge,death occurred at the time,date and place w Z 24e.On the basis of examination and/or investigation,in my opinion death occurred at
<br /> g c and due to the cause(s)stated.(Signature and Title) the time,date and place and due to the cause(s)stated.(Signature and Title)
<br /> x Chad Vieth,MD
<br /> 25.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b.WAS CONSENT GRANTED?
<br /> ❑YES ®NO ❑PROBABLY ❑ UNKNOWN ❑YES ®NO Not Applicable If 26a is NO ❑YES ❑NO
<br /> 27.NAME,TITLE AND ADDRESS OF CERTIFIER(Type or Print
<br /> Chad Vieth, MD,2116 W Faidley#400,Box 9802,Grand Island, Nebraska,68803
<br /> J28a.REGISTRAR'S SIGNATURE A I '� _ 28b.DATE FILED BY REGISTRAR(Mo.,Day,Yr.)
<br /> December 30,2014
<br />
|