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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 />
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