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To be completed /verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) William Fred Schritt 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) January 25, 2016 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE - Last Birthday (Yrs.) 77 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) May 24, 1938 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -40 -1971 8b. FACILITY -NAME (If not Institution, give street and number) 4th And Plum Streets 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ® Other (Specify)Lot/Field 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 2316 Park Drive e. 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 Ellen Thorpe 11. FATHER'S -NAME (First, Middle, Last, Suffix) Martin Schritt 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Rose Stoddard 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Karen Lee Reinhardt 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) January 28, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY 1 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) To be completed by: CERTIFIER .■■.] 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 onset to death Seconds 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: IMMEDIATE CAUSE (Final a) Gun Shot To Head disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b) I any, leading to the cause listed 1 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) I I 1 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 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 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) January 25, 2016 22b. TIME OF INJURY 11:48 AM 22c. PLACE OF INJURY -At home, A Field Located At 4th And Plum farm, street, factory, office building, Streets 22d. INJURY AT WORK? ❑YES 01 NO 22e. DESCRIBE HOW INJURY OCCURRED gunshot to head 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 4th And Plum, Grand Island Nebraska 68801 a W i, rc r E § z 23a. DATE OF DEATH (Mo., Day, Yr.) a u w 1 t;' k y • o. 4 z I &3 0 z 2 zz p 8 24a. DATE SIGNED (Mo., Day, Yr.) January 26, 2016 24b. TIME OF DEATH Approx. 11:49 AM 23b. DATE SIGNED (MO., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) January 25, 2016 24d. TIME PRONOUNCED DEAD 11:54 AM s Q 0 3d. To the best of my knowledge, death occurred at the time, date and place g 2 and due to the cause(s) stated. (Signature nd Title) 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) Gail VerMaas, Hall Deputy County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO 26b. WAS CONSENT GRANTED'? Not Applicable If 26a is NO ❑ YES ❑ NO 4 1 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Gail VerMaas, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 128a. REGISTRAR'S SIGNATURE_ jej 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 28, 2016 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 Fait VITAL RECORDS. DATE OF ISSUANCE 02/03/2016 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 201606141 S DOPER ASSISTANT STATE'1REGISTRA/ DEPARTMENT OF - HEALTH AND HUMAN SERVICES 16 00420