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STATE OF NEBRASKA
<br />Al&rr;
<br />A 10
<br />WHEN THIS ! COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />5/16/2016
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH'. AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Marjorie Edith Schultz
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cairo, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507 -60 -9942
<br />8b. FACILITY-NAME (if 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 />ea. RESIDENCE - STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />804 N. Boggs
<br />Oa. MARITAL STATUS AT TIME OF DEATH ❑ Married ® Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, Or Unk.) NO
<br />15. METHOD OF DISPOSITION
<br />Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
<br />Sequentially fiat condttitala, if
<br />any, leading to the cause llnted
<br />on line a
<br />: Enter the UNDERLYING CAUSE
<br />(disease or )n)urtf lfMt initiated
<br />the events resulting; in death)
<br />....
<br />2d
<br />, HO yes ❑ NO
<br />9b. COUNTY
<br />Hall
<br />16a. EMBALMER- SIGNATURE
<br />Christopher J. Loecker
<br />a a
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />W J May 9 2016
<br />23c. TIME OF DEATH
<br />o z 03:15 PM
<br />a. 0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />2 c SI and due to the cause(s) stated. (Signature and Title)
<br />fl
<br />¢ATE OF ogATH (Mo., Day, Yr.)
<br />May
<br />Richard
<br />I ar d f rue l'
<br />ling, MD
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Richard Fruehlin•, 2116 W Faidley #400, Box 9802, Grand Island,; Nebraska, 68803
<br />28a REGIST
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />91
<br />5b. UNDER 1 YEAR
<br />MOS,
<br />DAYS
<br />9e. APT. NO.
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />❑: ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />9f. ZIP CODE
<br />68803
<br />'Mb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nante
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Schultz
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Augusta Stange
<br />14a. INFORMANT -NAME ?.
<br />Leon Van! Winkle
<br />16b LICENSE NO.
<br />1421
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Berwick Cemetery
<br />CITY / TOWN
<br />Cairo
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ADfel Funeral Home. 1123 W. 2nd, Grand Island, Nebraska
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />May 6, 2016
<br />6. DATE OF BIRTH (Mo., Day, Yr)
<br />July 5, 1924
<br />28b. DATE FILED BY REGISTRAR (Mt
<br />May 10, 2016
<br />9g. INSIDE CITY LIMITS
<br />®YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />16c. DATE (Mo., Day, Yr.)
<br />May 9, 2016
<br />I 7b. Zip Code
<br />68801
<br />IMMEDIATE CAUSE:
<br />a) Pneumonia
<br />CAUSE OF DEATH (See instructions and examples)
<br />6. 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,
<br />respiratory arrest, or vemrictdar fibrillation without showing the etiology. DO NOT ABBREVIATE, Enter only one cause on a line. Add additional lines if necessary.
<br />APPROXIMATE iI NTERVAL'
<br />1 Week
<br />NATURE
<br />Day, Yr.)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 123 NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at . time of death
<br />© Not pregnant but pregnant within 42 days of death
<br />❑ Not pregnant, Out pregnant d3 days to 1 year before death
<br />❑ ikdcnown d pregnant within the past year
<br />21a. MANNER OF DEATH
<br />0 Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />Pedestrian
<br />0 Other, (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH ?,
<br />❑YES ❑NO .
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b, TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.1 24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and /or Investigation, in my opinion death occurred r
<br />the time, date and place and due to the cause(s) stated. (Signature and. Title)
<br />25. DIP TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 1 ❑ YES Not Applicable if 26a is NO 0 YES ❑ NO
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