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I. - DECEDENT'S -NAME (First, Middle, Last, Suffix) ::
<br />Wi lliam Dean Schmer
<br />2. SEX
<br />Male.
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />August I22, 2013
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Se. AGE -Lest Birthday
<br />(Yrs.)
<br />74
<br />5b. UNDER 1 YEAR
<br />':Sc. UNDER
<br />HOURS
<br />I: DAY
<br />MINE.
<br />S. DATE OF BIRTH (Mo., Day, Yr.)
<br />June , 21 I 1939
<br />Grand Island, Nebraska
<br />MOS. -
<br />DAYS
<br />.. _ T. SOCIAL SECURITY NIMIBER'.
<br />506- 424341
<br />Fa. PLACE OF DEATH
<br />HOSPITAL: ❑Inpatient MIS (tNursirlg ❑ Hospice Facgity
<br />0 . ERbU1WtiMt _; Q Decedenya Home
<br />DD1 ❑,wwr(Speaq)
<br />Bb. FACILITY -NAME (I1 not institution, give street and number)
<br />Tiffany Square Care Center
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d, COUNTY OF DEATH
<br />Hall
<br />9s:RESIDENCESTATE
<br />Nebraska
<br />Cti.COWTY
<br />Hall
<br />Ba CITY OR TOWN
<br />Grand Island
<br />gd. STREET AND. NUMBER : ::
<br />1332 Sherman place
<br />Be. APT. NO
<br />at 2IP.CODE
<br />68803
<br />99. INSIDE CITY LIMITS
<br />XI YES a NO
<br />10a. MARITAL STATUS AT TIME OF DEATH a Married ❑ Never Married
<br />tarried, but separated ❑ Widowed ❑ Divorced U Unknown
<br />1 Ob. NAME OF SPOUSE (First. Middle, Lest, Suffix) If wife give maiden name.
<br />Sue : Holbert
<br />11. FATHER'S -NAME (First, Middle, Last, G. Suffix)
<br />Louis Schmer
<br />12 MOTHER'S -NAME (First, : Middle, Maiden Surname)
<br />Flonnie Becker
<br />19. EVER IN U.S. ARMED FORCES? Give dates of service If yes.
<br />(Yes, no, orunk.) No
<br />14a. INFORMANT-NAME
<br />Sue Schmer
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />❑Burial l3 Donation
<br />xi crampon ❑ E n t om b men t
<br />❑ Rem oval ',' 0 Other (Speciy)
<br />lea. EMBALMER-SIGNATURE
<br />Not Embalmed
<br />16k. LICENSE NO.
<br />tee. DATE Mo., Day, Yr, ) :
<br />August 23, 2013
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streeet, City orTown,State)
<br />All Faiths Funeral Home, 2929 S. Locust, Grand Island NE
<br />18. PART I. Enter the X) ain of avant -- diseases, injuries, or complications-that directly caused the death; DO NOT enter terminal events such as cardiac arrest, APPROXIMATE
<br />respiratory arrest, or ventricular 'fibrillation without showlnptth eti DO ABBRREVI,. Enterynly one Cau a one line. Add additional lines if necessary. I
<br />IMMEDIATE CAUSE: "22 7 " e `y" , ° fl ' J / ra i onset
<br />• SIMEDIATECAUSE(Flnsl W f0 ! t.t' G� "./k7f " ' - i
<br />17bi' Zip Code
<br />68801
<br />INTERVAL
<br />to death
<br />dam orcarsea
<br />In Vieth)
<br />Sequentially
<br />tlnrouling DUE TO, OR 0.SEOUENCE OFF :.. onset In death
<br />Net conditions, II N : �U/V „3 / /:e Gr,'j4H.7 I ao
<br />any M 01 0 14414 auageled DUE TO, OR ASACONSEQUENCE OF: ' death
<br />anima.
<br />6ertrteUeLETrLY1M3DAUSE
<br />(dleMMalryby ISM WOW I
<br />tlravensims4 Mng kids." :.. DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />UST
<br />(d)
<br />18. PART II, OTHER SIGNIFICANT CONDITIONS contributing to the death but not resulting in the underlying souse given In PART I.
<br />�-y /�
<br />, : ..,_ / /Cxh VC1�� /oe � ��i - -e /Pet( IA.
<br />IS WAS MEDICAL EXAMINER
<br />' OR CORONER ACTED?
<br />❑ YES 4 NO
<br />20. IF FEMALE:
<br />❑Not pregnant within past year
<br />Q Pregnant at time of death
<br />Not pregnant, but pregnant within 42 days of death
<br />O Not pregnant but pregnant 43 days to l year . before death
<br />O unknown II pregnant within the peat year '1�
<br />21a. ER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident❑ Pending Investigation
<br />❑ Suicide (3 Could not be determined
<br />21b.IF TRANSPORTATION INJURY
<br />❑ Dover/Operstor
<br />O Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />S
<br />❑ YES 0
<br />vM
<br />O
<br />U
<br />Pedestrian
<br />Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />O YES ❑ NO
<br />2 2a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY-At home, farm, street. factory. off Ice building, cnnntructlnn
<br />cite, etc. ISpecity)
<br />22d. INJURY AT WORK?
<br />❑ YES ID NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />y
<br />221. LOCATION OF INJURY - STREET A NUMBER, APT. NO. CITY/TOWN'. :STAE ZIP CODE
<br />23a. DATE OF DEATH (Mo. Day,Yr.)
<br />August 22,2013
<br />E
<br />r
<br />w
<br />24a. DATE SIGNED (Mo., Dey, Yr.)
<br />24 TIME OF DEATH
<br />m
<br />233 DATE SIGNED (Mo., Day, Yr.)
<br />August 23, 2012
<br />23c,TIMEOF DEATH
<br />9:35 a m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRDNOUNCED DEAD
<br />m
<br />23d. To the beat of my , - ea - , can - et the lime, date and place
<br />and due tot Sign end Thb) w
<br />...,.
<br />24e. On the bash of examination and/or invesbgetion, in my opinion death occurred at
<br />§:: the time, date and place and due to Stecause(s) stated. (Signature and Title ):
<br />B >
<br />25. DID TOBACCO r SE CONTRIBUTE TO THE DEATH?
<br />❑ YES NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES A O -
<br />MM. WAS CONSENT GRANTED?
<br />Not Applicable If 285 le NO O YES 10
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER ( PHYSICIAN, CORONER'S PHYSICIAN OR COU A RNEY) (Type or Print)
<br />Jana ;A McDonald M.D. ' 800 Alpha st Grand Island NE 68803
<br />28a. REGISTRAR'S SIGNATURE.
<br />int if . 17600
<br />25b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.) . .
<br />AUG 2 9 2013
<br />DATE OF ISSUANCE
<br />09/04/2013
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH L AND KUMAA veRVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEf. R.4SKA DEPARTMENT EbF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR `VITAL4 RECORS,S: ' ". " 1
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />CERTIFICATE OF D EATH
<br />STANLEY S.,COOPE t
<br />A T'STATE k GI$TRAR
<br />DO4.4RTMENT ODF HEALTH ,4
<br />HUMAN' .5EI V E ; 7
<br />r ti' • <� i � A r Zb-
<br />1 3
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