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<br />ittuati(a)stat . SI P an
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<br />• •
<br /># •
<br />2, DATE OF DEATH (615 .Day,Yr.)
<br />June 19, 2016
<br />6 DATE OF BIRTH teAo , Day,
<br />June 3, 1941
<br />JUN 27 201
<br />26b, DATE 44.4*) EXY REGISTRAR 1160., Day, YAT
<br />.:, NE PART/517E1R SIGNIFICANT C NOIT NS-Condttions Co»triburing to Ws dorelfibutiaut rata
<br />;.< •::: II ' ::::I :, tOritt St „Sio unded91(9064 cause given in PART I,
<br />• II I .,,
<br />29, IF FEMALE: a, MANNER OF DEATH
<br />a • El H .. ... ...: ...
<br />: 1:114 Pr.! :eiSg)4t 0 .0(4)0 ow tural llitS*. ' "4'.
<br />(7.4ii.
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<br />„:::::,,,,,,,, Aoutdon1 Wind intreatipatiott ::..
<br />Se40410 ' 0 QT444 Ti4 tie tiatienatarued
<br />„ ow. I, ,t, (ua ' itt 42 4 r7E Wrath
<br />6We:1w p"
<br />904 42 'IA" 44 1 y'""4't° re death
<br />it pregnant within *ha pest year
<br />5.26,0AMDE'RIPURY (Mo„ Pay, Yr.)
<br />22d. INJURY AT
<br />0 YES
<br />25a, DATE OF DEATH (Mo , Day, W.)
<br />June 19 , 2016
<br />SIGNED (4'o., (209,
<br />2016
<br />*4 osettis4g
<br />54P:
<br />13.N
<br />228. 11148 04 INJURY
<br />2 o. DESCRIBE HOW INJURY OC
<br />?#6:.LOC OF INJURY -, STREET 6 NU ER, APT. No.
<br />.. .
<br />. ..
<br />. .
<br />. . ..
<br />.. .
<br />........:. : .
<br />ZS:PO 4 ONTROSUTE 10 TelE 06 T
<br />0 PROBABLY 0 KNOWN
<br />. ;
<br />'NAME; VELE AND ADDRESS OF CERTIFIER (Type or West)
<br />11 194404414
<br />ea PIACI OF DEATH
<br />1.10111,4 0
<br />0 Esiouusumnt
<br />o
<br />Da,
<br />1(0.44 TRANSPORTATION N I
<br />0 DrigeriDuatatur
<br />o Paltatinvet
<br />peelestRan
<br />0 Other (616iest7Y)
<br />Hawing HorrialLTC
<br />0 Decedent's Home
<br />Dotn.:(sp.eily)
<br />ad COUNTY OF DEATH
<br />Hall
<br />lac. DATE tMe., Day, 71.)
<br />June 23, 2016
<br />*981*084*1441
<br />1 . WAS MEDICAti E F4
<br />OR CORONER CO ACTED/
<br />o YES NO
<br />21e, WAS AN AUTOPSY FpF ED?
<br />OYES ier0
<br />wesE AUTOPSY FINDINGS AUWLASS
<br />40 1)01441.8416 CAUSE OP DEATH?
<br />0 TKO
<br />22o, PLACE 9F Ihoufee-A4 home, fit ,o street fantoiy, aft,* building, construction site, ate (Spesii
<br />STATE ZIP CODE
<br />24e. ISATE StGNED (Mo., Dag, 245. TIME OF DEATH
<br />m
<br />• Z >,
<br />42 4)2
<br /><
<br />24o PR UNCED ttila Day, Yr.) 24d, TIME PRONOUNCED DEAD
<br />1.244 *114 41* 4444s of examination *suitor inveatigatiOn. 4818y WAtxxid 444E5 4
<br />3 . oh. time, dote and place and Was to (ha sause(s) s(ated, (Signature ,d1)(42)
<br />1,20
<br />26e HAS ORGAN OR 145909 De ATKIN EWEN (IONSIDEREt)? 2814 WAS CONSENT GRANTED?
<br />. .:.. .7 . ..
<br />0 YES . •• IS NO . • Not Applioabla If 26a is NO 0 YES :: I40 .:.
<br />. • . . •
<br />-------- . .— —
<br />• . •
<br />.. • .. ........ .
<br />...Grqeff,11,..1:101:srask6
<br />7. s041,....840eR419 NUMBER
<br />' . ; • 505
<br />STI EACILITY.NAME {If rot iniditution, 9400416021804 marnoert
<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,
<br />RECORDS -OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />2
<br />5
<br />DATE OF ISSUANCE
<br />06/29/2016
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />t.De42e04141"$.NAME Middle, Last, 9849,81
<br />• Pact. James Schafer
<br />4 CITY *NV . .4101E OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a 4140.1.8 4 401) 1 4 8 9 55- UNDER 1 YEAR 5c. UNDER 1 DAY
<br />(7064 M09, 4)499 HOURS ratES.
<br />Wedgewood care Cente
<br />ork Teveze? DEATH Driniude
<br />Grand (51.940 '68603
<br />lia RESIDENCE
<br />94.1)009144
<br />Neoraska Hall Doruphan
<br />84. STREET ANON 2 tie APT. NO, , ZIP CODE • --,- , , _,, , 68832
<br />65 \IV. <San Rd
<br />er
<br />15e, MARITAL STATUS AT 14144 0? DEATH al Married 0 Newer Mardedi 10b. sAme Of SsoUSE tFirat, Mirlite, Lattt, 9oi494o)14 8448,, livii maiden names,
<br />Married, (.0.41 083)444(004 D Widowed 0 DWarciad 0 Unknown Joyce A Boltz
<br />11 PATHEEPS-NAME (F)rst, Middle, Last, Sortie) 12, MOTHER'S (First Middle, Malden Surname) •
<br />Fltoian D Schafer • ,“ j Aileeo O'Connor
<br />13, 41449 Re LEP ARMED FORCES? Gies dataa or eervIre tr Yea. 14a, WFORMANTWAME
<br />Yaw, No, re Unk.) No 0y44(0 A Schafer
<br />16,. ET2400 De DISPOSMON
<br />, MEMomtmorit
<br />449*%0ATg1)40010841
<br />11 : o8.:11*44*4114108,440401404 84
<br />40.10 )
<br />7 7.; •
<br />triter pea UNDERLYING CAUSE (I)
<br />triiattase ce.ittfttpt Milittled
<br />Oro ovvntA rAp•olting 044W
<br />LAST
<br />168. , MER /
<br />1 •
<br />164. CEMETERY, 1RER(71TO Y OR OTHER LOCMION 01'Y/TOWN
<br />Cedar Cemetery Doniphan
<br />17a FUNERAL HOME NAME AND MAIUNG APDRESS (Week, City 01 Town. slow
<br />Ctean.funeral Chapel, 3005 S. Locust Si , Grand Island, Nebraska
<br />CAUSE OF DEATH (Ste Instructions ant examples)
<br />14 PART T 4 4140 40440068081141 • tAs0,00 cotnthteattan. th.t 81011(00 0.00081.* 41420 fT04*04 .3ter*R■etisksai .ama 00011 na r4,410c 444 INTERyAL
<br />a ,aat, w fituatatirei weenie showing Re seaway 00 NOT 44044V44444 4044 noty 444 an a imp. 444 tteilli00041 3(
<br />IMMEDIATE CAL/SE:
<br />tr
<br />R AS A C484E4)4ENCE OF
<br />60404,1144149 44 40 If
<br />402,404440940 (98 114*100 40(04
<br />00 1019 a CRIE 10, OR AS A CONStAjk/kNCL 02.
<br />OUE TO, OR AS A CONSEQUENCE Ot
<br />201608811
<br />'4,, CITY OR TOWN
<br />• SEX
<br />165, LICENSE NO,
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />INSVE cp 06195
<br />Yea
<br />STATE
<br />NebraS)o(0 .1
<br />,*•
<br />75, Zip Cad*
<br />68801
<br />0884110 death
<br />.-+A--<-
<br />6,1081,,, 49010.
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