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To be completed by: CERTIFIER 1 F To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Leo Jon Schritt 2. SERE 4♦ + ` °, Male: ;,,,, :3 bATE. OF DEATH (Mo., Day, Yr.) April 6, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 78 5b. UNDER 1 YEAR 5c. UNDER 1 DAY ' '6. DATE OF BIRTH (Mo., Day, Yr.) July 23, 1936 MOS. DAYS HOURS MINS. 7. SOCIAL. SECURITY NUMBER 508 -38 -1322 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8b. FACILITY -NAME (If not Institution, give street and number) 304 East 15th Street 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 304 East 15th Street 9e. APT. NO. 9f. 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 Aletha June Warnke 11. FATHER'S -NAME (First, Middle, Last, Suffix) Martin Schritt 12. MOTHER'S -NAME (First, Middle, Maiden Sumame) Rose Stoddard 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Aletha June Schritt 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) April 8, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, 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 enter terminal events such as cardiac arrest, 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: onset to death IMMEDIATE CAUSE (Final a) Deeply Penetrating Gunshot Wound To The Head Immediate disease or condition resulting - in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) I any, leading to the cause listed I I on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) 1 (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 1. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 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 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 El NO 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) April 6, 2015 22b. TIME OF INJURY Unknown 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Outside Of Residence 22d. INJURY AT WORK? ❑ YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED Self inflicted gun shot wound to head. 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 304 E 15th Street, Grand Island Nebraska 68801 . w g $ '4' r a w e E v 2 23a. DATE OF DEATH (Mo., Day, Yr.) .2 g § i a o Ea. < 24a. DATE SIGNED (Mo., Day, Yr.) April 9, 2015 24c. PRONOUNCED DEAD (Mo., Day, Yr.) April 6, 2015 24b. TIME OF DEATH Approx. 08:00 PM 24d. TIME PRONOUNCED DEAD 08:11 PM 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH O 23d. To the best of my knowledge, death occurred at the time, date and place 2 c a due to the cause(s) stated. (Signature and Title Lit or�i' w z 2 0 u o 6 0 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Sarah Carstensen, Chief Deputy Hall County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN 26a. HAS ORGAN OR ❑ YES ISSUE DONATION BEEN CONSIDERED? El NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sarah Carstensen, Chief Deputy Hall County A torney, 231 S. Lo P.O. Box 367, Grand Island, Nebraska, 68802 1 28a. REGISTRAR'S SIGNATURE 4 I •NQ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 13, 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 NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR .V,ITAL' RECbRDS. DATE OF ISSUANCE 04/16/2015 201507479 STANLEY`S Coder ,ASSISTANT STATE REIS'TRAR DEPARTMENT OF 11EAL tH, 116 LINCOLN, NEBRASKA 1-1UJMA(V - SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMANSEkVICES CERTIFICATE OF DEATH 15 02128