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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ANp HUMAN SERVICES, IT CERTIFIES <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL'RECOR1s. <br />DATE OF ISSUANCE <br />10/09/2015 <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA <br />201507723 <br />STATE OF NEBRASKA - DEPARTMENT OF -HEALTH AND HUMAN SERYIC <br />CERTIFICATE OF DEATH <br />STANLEY S. COOPER <br />ASSISTANT STATE REGIS1,, <br />DEPARTMENT OF HEAL AND e <br />HUMAN SERVICES <br />7. SOCIAL SECURITY NUMBER <br />-- 507 -58 -7759 <br />80. FACILITV.NAME (t not Institution. give street and number) <br />CHI Health St. Francis <br />8c. CITY OR TOWN OF DEATH (Include Zip Code) <br />Grand Island 68803 <br />9d. COUNTY of DEATH <br />Hall <br />1. DECEDENTS -NAME (First, Middle, Last SIASx) <br />Dolores Jean Schutter <br />4. CITY AND STATE. OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6a. AGE•Last Birthday 50. UNDER 1 YEAR <br />"4 MOS. 1 DAYS <br />Omaha, Nebraska, United States <br />73 <br />8aa. PLACE OF DEATH <br />HOSPITAL: 0 inpetent <br />ER/Outpatient <br />Q DOA <br />OTHER: 0 Nursing Horne/LTC 0 Hospice Facility <br />U Decedents Home <br />Q OthettSp•cify) <br />9a. RESIDENCE -STATE <br />Nebraska <br />90. COUNTY <br />Hall <br />8c. CITY OR TOWN <br />Grand Island <br />9e. APT. NO. <br />9f. ZIP CODE <br />68801 <br />19g. 114810E CITY LIMITS <br />Fi Yes © No <br />9d. STREET AND NUMBER <br />809 E. Bismark Rd r <br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Mani it� 100. NAME OF SPOUSE (Feet, Middle. Last, Suffix) If wife, give maiden name. <br />0 Masted, but separated 0 Widowed ® Divorced 0 Unknown <br />11. FATHER'S -NAME (First, Middle, Last, Suffix) <br />Everett Matthews <br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yee. 14a. INFORMANT -NAME <br />(Yes, 140, or Uak.l No Tina <br />12. MOTHER'S•NAME (First, Middle, Malden Surname) <br />Delores Brisbane <br />140. RELATIONSHIP TO DECEDENT <br />Daueter <br />1 16b. UCENSE 140. <br />2. SEX <br />Female <br />UNDER 1 DAY <br />(HOURS i MINS. <br />3, DATE OF DEATH (Mo.,Day,Vr.) <br />September 4 2015 <br />8. DATE OF BIRTH (Mo.,,1 ' 7, Yr.l <br />August 26, 1942 <br />16c. DATE (Mo., Day, Yr.) <br />September 7, 2015 <br />16d. CEMETERY, CREMATORY OR OTHER LOCATION <br />Central Nebraska Cremation Services <br />CIT frtOWN <br />Gibbon <br />STATE <br />Nebraska <br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Sleet, City or Town, State) <br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska <br />17b. Zip Code <br />68801 <br />I . PART L E ntN114 <br />wsp4.tay attaat.'ar watkular nb eMaeon <br />IMMEDIATE CAUSE: <br />IMMEDIATE CAUSE (Final <br />disease or condition resulting a) <br />In dearth) <br />DUE TO, OR AS A CONSEQUENCE OF: <br />Sequentsity item conditions, t <br />any, leading to the cause listed 111 <br />CAUSE OF DEATH See Instructions and exam t les <br />amens that dreamy memo the dente. Do • T enter wanted ewnw such es cantles emus, <br />.tkaaa,. 00 NOT AaeREVIAtt. Tatar may ant ammo an a an.. Add additional lima If n.a.a4n. <br />APPROXIMATE INTERVAL <br />onset to death <br />onset to death <br />P <br />18. METHOD OF DISPOSITION 16a. EMBALMER•SIGNATURE <br />O9una1 Qponation <br />( cremation Qtnttmbnmm <br />❑8enovai 00thenliemlfin <br />Not Embalmed . <br />onset to death <br />den <br />V <br />on line 4. DUE T0, OR AS CONSEQUENCE OF: w Q ,,� ,p D, Aw <br />Enter the UNDERLYING CAUSE 4) C k v . tip• 0 (eA v-C 1 - `r ! ' ∎• <br />(disease or injury that Initiated <br />DUE TO, OR AS A CONSEQUENCE OF: <br />the events resulting In death) <br />LAST <br />4) <br />onset to deem <br />18. PART I // (.OTHER siGNtigCANT CONDITIONS - Conditions contributing to the death but not ewltlng In the underlying cane given In PART I. <br />I R <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />O YES a( NO <br />20.1F FEMALE: <br />14Net pregnant within past year <br />°Pregnant at time of death <br />Q Not pregnant, but pregnant wihln 42 days of death <br />❑Not pregnant, but pregnant 43 days to 1 year before tea <br />QUnknown H pregnant vnthln the past yea <br />219. MANNER OF DEATH <br />'Natural 0 Homicide <br />Q Accident 0 Pending investigation <br />Q Suicide 0 Could not be determined <br />210. IF TRANSPORTATION 114.10 <br />Q oriverlOperator <br />Q Psessrpa <br />[]. Psdsebian <br />Q Other (Specify) <br />21c. WAS AN AUTOPSY PERFORMED? <br />Q YES NO <br />21d. WERE AUTOPSY FINDINGS AVAILABLE <br />TO COMPLETE CAUSE OF DEATH? <br />❑YES 0 14 <br />22a. OATE OF INJURY (Me., Day, Yr.) <br />22d. INJURY AT WORK? <br />Q YES Q NO <br />220. TIME OF INJURY <br />m <br />22e. DESCRIBE HOW INJURY OCCURRED <br />22c. PLACE OF INJURY -At home, Tarn, street, factory, office building. construction site. etc. (Specify) <br />22f. LOCATION OF INJURY • STREET & NUMBER APT. NO. CITY/TOWN <br />STATE ZIP CODE <br />23a. DATE OF DEATH (Mo., <br />Oq <br />230, DATE SIGNED (140 <br />va / aYl <br />© .}U /r? <br />DaY Yr.) <br />23c. TIME OF DEATH <br />(0. <br />23d. To the best of my knowledge, death occurred at the ltlft.,date and plat <br />and due to the calla.{.) stated, gnetute and Tide) <br />264. HAS ORGAN OR 11880E DONA <br />P NO <br />(3 vas <br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />( Q NO °PROBABLY 0 UNKNOWN <br />27. ME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) <br />2‘0LC Ca-- S e'tV1I -. hA <br />29a. REGISTRAR'S SIGNATURE <br />/tie A <br />GL.L 1� <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) <br />m <br />24e. On the basis of examination and/or investigation, in my opinion death occurred <br />at the thee, date and place and due to the cause(.) stated. (SIgnatue and Tae) <br />N BEEN CONSIDERED? <br />2411. TIME OF DEATH <br />24d. 116115 PRONOUNCED DEAD <br />m <br />260. WAS CONSENT GRANTED? <br />Not Applicable t 26a le NO 0 YES 0 NO <br />00120 WA-1 tfe 64te <br />{ 280. DATE FILED BY REGISTRAR (Mo., Day, Yr.) <br />SEP 1 7 2015 <br />