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n <br />M <br />f1 <br />;a <br />M <br />"n <br />D p <br />_ to <br />C) <br />ter' <br />RAYMMD CARL SCHOLTZ <br />place Decembe t 30, 1918 <br />[ -N. }. YYbiRO, A�Orip. <br />OYOINIplSCENT(9.11 M MoRinN. AGE <br />- <br />rr <br />= <br />fr•ii... !(SPoeJy► _ <br />ORr.RL)fSPociFy) .. (Vra.) <br />16.. <br />NOS. DAYS <br />HOURS . MINI <br />AwAican <br />Crn'I <br />= <br />STATE AND OF RlRTN ..I in U.S.A., N p WHAT COUNTRY <br />o <br />C-3 cn <br />o <br />CD <br />7c <br />SOCIAL SECURITY R USUAL OCCUPATION (G" ki NI of w.rk deco tf.0i -R -nM <br />moor SUSINESS OR DNOUSTRY <br />►-A <br />o -a <br />z 1). <br />N <br />C. <br />12.507 -16 -4874 l 1x <br />TA.. <br />CITY, TOWN OR LOCATION OF DEATH INSIDE <br />CITY LIMITS <br />HOSPITAL OR OTHER INSTITUTION - NW* (N -N .N orlAor. <br />» NOSr Cie 194T I.A.... DOA. <br />(SpecarToe <br />114e. <br />or N.) <br />R:.0 so op.Nd ovmbw) <br />1,4a. <br />O.�POO•N /I-- � . I•r.0•N (So«dr) <br />I . Grand Wand <br />yew <br />St. e A Med ' Ceri teA <br />1490 DOA <br />RESIDENCE -STATE <br />'STS <br />CA) <br />C, -n <br />o <br />.� <br />Hatt <br />113C. Gncu:d Ida d <br />Iim. 4355 W. Calgtot <br />j;SPOC41fesw"o) <br />5. <br />-ri <br />_y�i <br />E - N MID l <br />Isbell <br />John A. Schottz <br />Ethet - <br />WAS DECEASED Mo IN U.S. ARMED FORCES? <br />(Y.. »,�......- ••.�..•.. <br />INFORMANT- NAM[ - RELATIONSHIP -MAKING ADDRESS (STRUT OR a r 0 "o-IT OR t T T0h <br />'O���d� <br />-..I <br />u. -kv ,�I <br />nOD <br />o <br />Jan . 3 <br />CEM[TERY OR CREMATORY - NAMI <br />LOCATION CITY Oe TOWN STATE <br />i2w <br />:D.. <br />97g <br />m. Grand 14tand Cemet ai <br />Grand 7.6tand. NebAa6ka <br />HOME -NAME AND ADDRESS IS1MI1 OR 1 F D. NO. CITY OR TOWN. StATI. LN) <br />e.t- Butt"- Geddeb 1123 W. 2nd Grand idtcuid. NE. 68801 <br />•••.-od M . 001• WW Pa.- WW b• w 0r <br />hVUNERAL <br />a1 /bo bo•i• tat <br />DATE SKR41D 1 . Yr.) <br />CD <br />C <br />o. y. r. <br />3b. 1-8-79 <br />• <br />g.' L M <br />O <br />:Ns. a... M <br />i <br />DATE OF DEATH (MO., Dory. Yr.) <br />j <br />iv <br />fA <br />` <br />o <br />s i <br />(M... D.r. Yr.) <br />CID <br />• <br />e <br />WHEN THIS COPYCARRWS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, R CERTIFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL REf6RD -ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISM't 4 VCfYhpf, - Wi1Ckl /S <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />DATE OF ISSUANCE Ojai <br />MAY 17 2001 - <br />ASSISTANT STATE REGISTRAR= <br />LINCOLN, NEBRASKA HEALTH AND INAMAN SERVICES SYSTEM <br />200105103 <br />STATE OF NEBRASKA— ORARTIIENT W NEAITN <br />amended BUREAU of YRAL STAraM 7 8 13906 <br />V-1. 1n t n7n CERTIFICATE OF OEATI*= - . <br />- -1 <br />DEATH (MO.. D.P. Yrj <br />RAYMMD CARL SCHOLTZ <br />place Decembe t 30, 1918 <br />[ -N. }. YYbiRO, A�Orip. <br />OYOINIplSCENT(9.11 M MoRinN. AGE <br />- <br />-Tort Ri h&w I UNDER 1 YEAR <br />UNM 1 DAY DATE Oi OM M (Me., Day, Yr ) <br />fr•ii... !(SPoeJy► _ <br />ORr.RL)fSPociFy) .. (Vra.) <br />16.. <br />NOS. DAYS <br />HOURS . MINI <br />AwAican <br />55 <br />fic. > Nov. T 1923 <br />STATE AND OF RlRTN ..I in U.S.A., N p WHAT COUNTRY <br />. NEYN MARRIED. NAM! OF SPOUSE (IT :ft. Roo «.i o0 0000) <br />-.moo sw . 1) <br />llARRI <br />WIDOWM.OIIFORC[DfSp . fdr) <br />III <br />R. Yg4gM0, Nebnaeka o. U.S.A. <br />1. 9" d <br />SOCIAL SECURITY R USUAL OCCUPATION (G" ki NI of w.rk deco tf.0i -R -nM <br />moor SUSINESS OR DNOUSTRY <br />0f."* YfR w.w i/ <br />113a `�' � <br />12.507 -16 -4874 l 1x <br />TA.. <br />CITY, TOWN OR LOCATION OF DEATH INSIDE <br />CITY LIMITS <br />HOSPITAL OR OTHER INSTITUTION - NW* (N -N .N orlAor. <br />» NOSr Cie 194T I.A.... DOA. <br />(SpecarToe <br />114e. <br />or N.) <br />R:.0 so op.Nd ovmbw) <br />1,4a. <br />O.�POO•N /I-- � . I•r.0•N (So«dr) <br />I . Grand Wand <br />yew <br />St. e A Med ' Ceri teA <br />1490 DOA <br />RESIDENCE -STATE <br />COUNTY <br />CITY. TOWN OR LOCATION <br />STREET AND HUNKER <br />NSIDE City LIIRITS <br />,,.. Nebraeka liw <br />Hatt <br />113C. Gncu:d Ida d <br />Iim. 4355 W. Calgtot <br />j;SPOC41fesw"o) <br />5. <br />A - MI <br />_y�i <br />E - N MID l <br />Isbell <br />John A. Schottz <br />Ethet - <br />WAS DECEASED Mo IN U.S. ARMED FORCES? <br />(Y.. »,�......- ••.�..•.. <br />INFORMANT- NAM[ - RELATIONSHIP -MAKING ADDRESS (STRUT OR a r 0 "o-IT OR t T T0h <br />'O���d� <br />-..I <br />u. -kv ,�I <br />r4". lkw Jo Schottz -Gk a -4355 W. C 'toy .- Lei c <br />BURIAL, Cnwastion. <br />Jan . 3 <br />CEM[TERY OR CREMATORY - NAMI <br />LOCATION CITY Oe TOWN STATE <br />i2w <br />:D.. <br />97g <br />m. Grand 14tand Cemet ai <br />Grand 7.6tand. NebAa6ka <br />HOME -NAME AND ADDRESS IS1MI1 OR 1 F D. NO. CITY OR TOWN. StATI. LN) <br />e.t- Butt"- Geddeb 1123 W. 2nd Grand idtcuid. NE. 68801 <br />•••.-od M . 001• WW Pa.- WW b• w 0r <br />hVUNERAL <br />a1 /bo bo•i• tat <br />DATE SKR41D 1 . Yr.) <br />M <br />im. <br />C <br />o. y. r. <br />3b. 1-8-79 <br />• <br />g.' L M <br />= <br />:Ns. a... M <br />i <br />DATE OF DEATH (MO., Dory. Yr.) <br />j <br />PRONOUNCED DEAD <br />_ <br />PRONOUNCED DEAD (NO.r) <br />` <br />1 Z. <br />s i <br />(M... D.r. Yr.) <br />-30 -78 <br />NAME AND ADMISS Of CINT0114 L 1 ONONEWS PHYSICIAN OR COUNTY ATTORNEY) (Typo or ►nM) <br />A(M 1 <br />26..E ..A..)B► � <br />DIATE CAUSE (EN R ONLY O E CAUSE PER LINE 1109,Mr(b). AND (c)1 CAM ..r•I ►N...w M.N •d rr••IA <br />PIYT <br />Acute cardiores otory arrest _ ___ , <br />DUE TO, WA--Z <br />ENC Iwl•rr•I bNo..w .n.N ..d N••A <br />,., Acute myocardial infarction <br />OUR TO, OR AS A CONSEQUENCE OF: N- &- 1 ►a.•.w .w.•1 •wa d..N <br />kl _ <br />PART AN - C•.d01.0..« «.►r0w/ w I.NA ► . wN r.h..0 <br />'Alt IN 11 I= WA� 1NIRI A <br />1.60MANCY IN TMl PAS 7 AWNTNSt <br />AUTOPSY <br />f30•e.lr YN « N•I <br />WAS CA> 1 R!Il1Rt0 10 M101(Al <br />I><A/ -INIR OR COIONIR <br />R <br />none <br />T. 0 No <br />1211 No <br />fSN.rIY . N N./ <br />129 T• <br />No <br />ACCIOIM, S111C101. NOMICIOI. 11NplT . DAte CM IN/URY 1M.. D.F. Yr I <br />NO' • of INIURY <br />04SC11e! NOW "URT OCCUNID - - -- <br />W PIN0»ra wvIS. T1oN (S,«+rl <br />30.. No 30b. 1 <br />70c. M <br />30d. <br />»UU" AT WOM <br />PIAC OF WUUfT -• M , Mw, Nr.N• 1 -0-Y• <br />1OCATION Sle!!T q R / 0 N• Clfi 01 Low" STATI <br />( Sru.Ar TN W r1•) <br />•#%.. bw§&.& •N f 1pwdT) <br />X01. <br />Lot Fourteen (14) in Block One (1) Le Heights Subdivision, being a part of the Northwest <br />Quarter of the Northwest Quarter (NI-11/4 N10/4) of Section 11, Township 11 North, Range 10 <br />