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nr,v 1 ,94 m c O O 0 0 v O a� E A X IV I � z W F. n W U L' W N 0 .c LL C1 STATE OF NEBRASKA — DEPARTMENT OF HEALTH BUREAU OF VITAL STATISTICS CERTIFICATE OF DEATH L7 .0 27 IMMEDIATE CAUSF. IFNI En ONLY ONE CAUSE rER LINE FOR TAI thl. AND kl) 1 a11MW LWwaen ernaen arin .urn UJ PART Iles Cardiopulmonary arrest 1 Minutes 7 lOL DUE TO. OR AS A CONSEOUENCE OF i ft .10 aalwUa poet am flak, L-i pX Congestive Heart Failure ; Years fh DUE TO. OR AS A CONSEQUENCE OF I kaerval beMeen pops end 6-A I 1 (c) 1/ R SIGNIFICANT CONDITIONS - a conl6butlrlp to the death bra not related PART � �oronary artery isease, Diabetes riell -i><- tension, Stro 1 Of 1:EDf.NT -NAME FIRST MIDDI F.. LAST 2. SEX 3. DATE OF DEATH (Month Day Yaarl 29a Mervin Junior. Schroeder Male February 11, 1997 LJ q% [J Paring Ilrn k_% MvPingahnrl s (11TY AND SLATE Of RIRTH IN rWk USA. no.Itc rrhyl 5e AGE Last R6tMAy UNDER 1 YEAR UNDER 1 DAY _ S. DATE Of BIRTH tAaorl,R Day L'a d _ St. Libory, Nebraska ly'.1 66 [Tb March 3, 1930 MOS 1 DAYS st.HDURS: MINS 7 SU;UL SECURTIY NUMBER Re PLACE OF DEATH HOSPIIAL ® Inpelea OTHER ❑ Nvolnp No.* 27e TIME OF DEATH 6:35 a 508 30 4880 -- 270. To I10 beet of my knowledge death occurred as On tlQnO dale It ld place and due to The tauaMfl slated. AA L 1__ ! : f ..-.' — • and T .I l - -'__ 260. On M bob d no thleaort andior krvas,pOon. In my opkwon death opptand M IM pale. dale and place and due o IM cat»Na) teased. and ❑ ER Ou"digni ❑ Residence Rh IA('ILITY. NA" IN not msehAbn, giw .Street end nranMrl 30 a HAS ORGAN OR TISSUE DONATION BEEN VA Medical Center, 2201 N. Br.oadwell ❑ DOA ❑ Oth.n/st -Ayl —_ -- Ae CIIN TOWN OR LOCATION OF DEATH M INSIDECItYLIMITS 9R COUNTY OF DEATH YES ® NO Grand Island, Nebraska Yes a No ❑ Hall 32b. DATEFILEDBYREGISTRAR 11da.0ey. "..1 9w of SIDE NCE ,I it Yb. COUNTY 9e C1/Y,iow, on LOCATION lid. STREETANONUMSER /A¢kimnp Zlo6 I M W. CIfY I'M Nebraska Hall Grand Island 1107 Centennial Dr. Yes IN No [l 10 IIACE lap.WNnr Stack. An,erVanindillaI 11. ANCESTRY Iep hAlian. Masi 'German. sites 12 MARRIED nWIDOWED to NAME OF SPOUSE if w11Y p.Y tnaeAwr narrrl N•11.1r00 White I ISPeo "1 German I- -j�N'EEVER DIVORCED Beverly Jean Smith lJ - 1.IA USUAL OCCL1PAt" IGr @ aMd of kork ddM durhrp r otI IAA KRID OF BUSINESS INDUSTRY 15. EOUCATION ISpecay pay highest grant conlpleedl Elemerae or Secondary to 121 CMepA ll 4 o S•t �2th _ M w+rk-.q tile. even NrnA.Ml Manager, Retired Bowling Center ir, FAIHFR NAME FIRST MIDDLE LAST 17 MO1RFn FIRST MIDDLE MAIDEN SURNAME (Liv.) Mervin NMN Schroeder (Dec.) Gertrude NMN Meinke IR YJAS DECEASED EVER IN US ARMED FORCES? 19a INFORMANT NAME IYet nn n 1qF I IN yet give war and does of somlces) Viet nam 1/6/55 -7/31 1 Beverly Schroeder INFORMANT MAILING ADDRESS ISinEFTORRFD NO. CITY OR TOWN. SLATE ZIPI [�es 107 Ce ial rive, Grand Island, Nebraska 68801 0 fM - SKiNAIURF ICE 71A MF.IHODOT'DISPOSNION 21b DATE 21e. CEMETERY OR CREMATORY NAME Swint ❑nemoYsl Feb. 14 1997 Grand Island City Cemetex 7a tI4ERALHdV NAME 21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE ' Livings on- Sonderman F.H. ❑QenalIca ❑Donal- Grand Island, Nebraska 7An rkINEnAl. HOME ADDRESS (STREET OR R.F.D NO. CITY OR TOWN. STATE. ZIP) 601 N. Webb Rd., Grand Island, Ne. 68803 -4050 L7 .0 27 IMMEDIATE CAUSF. IFNI En ONLY ONE CAUSE rER LINE FOR TAI thl. AND kl) 1 a11MW LWwaen ernaen arin .urn UJ PART Iles Cardiopulmonary arrest 1 Minutes 7 lOL DUE TO. OR AS A CONSEOUENCE OF i ft .10 aalwUa poet am flak, L-i pX Congestive Heart Failure ; Years fh DUE TO. OR AS A CONSEQUENCE OF I kaerval beMeen pops end 6-A I 1 (c) 1/ R SIGNIFICANT CONDITIONS - a conl6butlrlp to the death bra not related PART � �oronary artery isease, Diabetes riell -i><- tension, Stro PART III IF FEMALE. WAS THERE A PREGNANCY IN THE. PAST 31 THS? (Age,10 -5a) YN NoEll 1 24 AUTOPSY Y« No 25. WAS CASE REFERRED TO MEDICAL EXAMMFR OR COAONER1 Yee No _ 29a 28b. DATE OF INJURY /M6. Day Yr.1 26c HOUR OF INJURY 26d, DESCRIBE HOW INJURY OCCURRED D( ActdeM 11 UnrlMerrrlirMd M LJ q% [J Paring Ilrn k_% MvPingahnrl 260. INJURY AT WORK Ye, ❑ No O 261. PPV E ,UUcRY ;�, larm, sheet. lackxy IF6tr AuI 269 LOCATION STREET OR R F D. NO. CITY OR TOWN STATE 27a DA IF OF DEATH /Ale Day. Vr1 280. DATE SIGNED (Ala. Day. Y1.1 M. TIME OF MAIN 6 t27b a 9 February 11, 1997 At � "`i h M -- DALE SIGNED /Mb. DeY Y,) Z / 27 27e TIME OF DEATH 6:35 a 26e. PRONOUNCED DEAD /Ala. OaY• YJ M. PRONOl1NCE0 DEAD (Mxal 270. To I10 beet of my knowledge death occurred as On tlQnO dale It ld place and due to The tauaMfl slated. AA L 1__ ! : f ..-.' — • and T .I l - -'__ 260. On M bob d no thleaort andior krvas,pOon. In my opkwon death opptand M IM pale. dale and place and due o IM cat»Na) teased. and 29 DIO '171c' USE CONTRIBUTE TO THE ATN7 30 a HAS ORGAN OR TISSUE DONATION BEEN CON9IDEREO? 30 b WAS CONSENT GRANTED? YES ❑ NO UNKNOWN YES ® N0 YES ® NO 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER 5 PHYSICIAN On COUNTY AT/ORNEY) ITypeor Pnn'l Aye -Aye K. Cheah, M.D., VA Medical Center, 2201 N. Broadwell, Grand Island, NE 63803 32s REGISTRAR 32b. DATEFILEDBYREGISTRAR 11da.0ey. "..1 FOR VITAL STATISTICS USE ONLY Place....................... A ................................ B ................................ C ................................ D ................................ E ................................ Part il ...................... TMV........................... NSC.................................................................................................................................................................................................................... ............................... Census Tract No. Work.............................................................................................................................................................................................:............................................................. ............................... tic................................................. ............................... r.......................................................................................................................................... ............................... Reject......................................................................................... m....................................................................................................,................... ........................... a)[I _... • Printed with eey Ink on recycled Pepsin hereby certify this to be a true and correct copy of the original filed with the State of Nebraska Signed in my day o Notary Public III GENERAL NOTARY-State of Nebraska TERRY L LOSCHEN My Comm. Exp. .y