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•+ Y m = y o <br />M CA z <br />M = � , o c.� .,. o ,.ry O <br />w <br />L 1, tp C!� <br />Ca r r> _C <br />Q CZ) ~ C4 <br />oo cn cn co <br />cn <br />REPORTER'S MEMO <br />WHEN THIS COPY GIRDS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, R CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL _21M RA E WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES4=76M, -VITAL STA '1 1V�IHWEH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ <br />DATE OF ISSUANCE <br />MAR 12 2001 200104135 <br />- R <br />LINCOLN, NEBRASKA HEALTH AND_M <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND ER MAN _ _ SBPPORT <br />VITAL STATISTICS e ^Y 1 02096 <br />CERTIFICATE OF DEATH - <br />1 DECEDENT - NAME FIRST MIDDLE LAST <br />2. SEX - <br />. DATE OF DEATH /MOntn Day ✓earl <br />Walter Eric Schinkel <br />Male - <br />February 22, 2001 <br />4. CITY AND STATE OF BIRTH (Hnotn USA.. name country) <br />Sa. AGE -Last Birthday <br />UNDER I YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Monts. Day, ✓earl <br />5b MOS DAYS <br />5c. HOURS' MINS <br />Ravenna, Nebraska <br />(Yrs.) 85 <br />OJ <br />April 3 , 1915 <br />7. SOCIAL SECURTIY NUMBER <br />Be. PLACE OF DEATH <br />508 -42 -3371 <br />HOSPITAL: ❑ Inpatient OTHER ® Nursing Home <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY - Name ld not rnsMUtion^ give street and number) <br />St. Francis Memorial Health Center <br />❑ DOA ❑ Other tspec'M <br />Sc. CITY. TOWN OR LOCATION OF DEATH <br />Rd. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yes M No 11 <br />Hall <br />9a. RESIDENCE - STATE <br />9b COUNTY <br />9c. CITY, TOWN OR LOCATION <br />9d. STREET AND NUMBER /Including Zip Codel <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />4313 Claussen Rd. 68803 <br />Yes ® No ❑ <br />10. RACE - (e.g.. While. Blaek. A.9MC n I dian. <br />11. ANCESTRY (e.g.. Malian. Mexican. Gemlan, etc) <br />12. ® MARRIED ❑ WIDOWED <br />13, NAME OF SPOUSE /e-* grw makW ,w W <br />e1c.l lSpecilyl White <br />1soecnvl American <br />MEVER DIVORCED <br />Eleanor H. Ninke <br />14a. USUAL OCCUPATION /Give kindot w k done during most <br />14b KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />of life. even if reared) <br />"" rmer <br />Agriculture <br />Element Secondary (012) College (1.4 or, 5.1 <br />16. FATHER - NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Edward Schinkel <br />1 <br />Minnie Pape <br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />(Y nno. or Unkl I (It yes, give war and dates of services) <br />no <br />Eleanor Schinkel <br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP( <br />4313 Claussen Road, Grand Island, NE. 68803 <br />MBA ER - SIGNATURE 8 LICENSE NO <br />21a. METHOD OF DISPOSITION <br />21b. DATE 21c <br />CEMETERY OR CREMATORY NAME <br />® Burial ❑Removal <br />Feb. 26, 2001 <br />Grand Island Cemetery <br />2a. FUNERAL HOME NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel - Butler- Geddes <br />❑ cremation ❑ Donator <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP) <br />1123 West Second, Grand Island, Nebraska 68801 <br />23. IMMEDIATE CAUSE �. (ENTER ONLY ONE CAUSE PER LINE FOR (a1. IN. AND (c)l Interval between onset and death <br />PART <br />1 <br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and death <br />I <br />I <br />IN Interval DUE 70, OR AS A CONSEQUENCE OF Onset and death <br />I <br />I <br />(cl <br />0 G I icons ibuting to the des A 1 IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL <br />PART �^ (� • PREGNANCY IN THE PAST 3 MONTHS. EXAMINER OR CORONER' <br />N ,�r'Gy�� �1•J <br />e (Ages 10 -54) Yes No Yes NO Yes No <br />I6a. 26b. DATE OF INJURY /MO. Day Yr.) 26c. HOUR OF INJURY 25d. DESCRIBE HOW INJURY OCCURRED <br />C3Accident 4 Unamen -reed M <br />n S.-.I - ❑ Pending 211e. INJURY AT WORK 261 PLACE OF INJURY- At home, farm. street. factory 26g. LOCATION STREET OR R.EO. NO. CITY OR TOWN STATE <br />❑❑ ❑ oXice building. etc. lSpecityl <br />Homicide Invesugatwn yes No <br />27a. DATE OF DEATH /Mo.. Day Yr.l 28a. DATE SIGNED /Mo.. Day. Yr.) 28b TIME OF DEATH <br />E_ d_C;0_ (3 � obi M <br />27b DATE SIGNED (Mo.. flDay, Yr.) 27c TIME OF DEATH g } 28c. PRONOUNCED DEAD III Day. YU 28d. PRONOUNCED DEAD /HOUrI <br />M i M <br />° 270 To the bast Of my k at the time, date and d e nd due to the ° � § 28e. On the basis of exammaeon and or investgahon. in my opinion death occurred at <br />causes) stated. ~ ° a the time. date and dace and due to the causelsl stated. <br />Si gnature and Title Si nature and Title <br />29 DID TOBACCO USE CONTRIBUTE TO HE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEE CONSIDERED' 30A WAS CONSENT GRANTED' <br />❑YES O ❑ UNKNOWN ❑ YES 10 ❑ YES NO <br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI I type or Prinb <br />Kimberly.A: Mickels M.D. 729 N. Custer, Grand Island, NE. 68803 <br />32a. REGISTRAR AAA l.N /N 320. DATE FILED BY REGISTRAR AR (Mo ' y2001 <br />Q <br />Q <br />