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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 FOR VITAL RECORDS DATE OP ISSUANCE 9/21/2017 LINCOLN, NEBRASKA 15. METHOD OFDISPOSiTtON ❑ Burial ❑ Donation ® Cremation ❑ Entombment Removal ❑ Other, (Specify) 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Eric Ronnie Schmit CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lincoln, Nebraska 7. SOCIAL SECURITY NUMBER 307 -11 -3163 Bb. FACILITY -NAME (tfttottnstitution, give street and numoer) 104 W. 20th St. S^. CITY OR TOW OF DE M1 TH If, C --±e) Grand Island 68801 90. RESIDENCE -STATE Nebraska ' 9d. STREET AND NUMBER 104 W. 20th St. Enter the UNDERLYING CAUSE (disease of mjerpthat inhie.tetl. the o resulti m death) LAST:: 10 a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated: ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ronnie Schmit 13. EVER IN U:S& ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 5a. AGE - Last Birthday (Yrs.) 36 9b. COUNTY Hall 5b. UNDER 1 YEAR MOS. 16a. EMBALMER- SIGNATURE Katie M. Smvdra DAYS 8a. PLACE OF DEATH HOSPITAL [3 Inpatient ❑ ER/Outpatient ❑ DOA - 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC ▪ Decedent's Home ❑ Other (Specify) I std, coUNTY OF DEATH Hall 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Patricia Delsing 14a. INFORMANT - NAME Bethany Sue Schmit 9f. ZIP CODE 68801 1Gb. LICENSE NO. 1454 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska . PART 1. Enter the chain of events diseases, injuries, or complications -that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter o one cause on a lined Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Sarcoma of Right Leg, Metastatic disease or condition resulting 3. DATE OF DEATH (Mo., Day, Yr.) August 15, 2017 6. DATE OF BIRTH (Mo. Day, Yr) September 27, 1980 ❑ Hospice Facility 9c. CITY OR TOWN Grand Island 9g. INSIDE CITY LIMITS E YES ❑ NO 10b.: NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Bethany Sue Nelson 14b. RELATIONSHIP TO DECEDENT Wife • 16c. DATE (Mo., Day, Yr } August 18, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) APPROXIMATE INTERVAL onset tc death 5 Years in death). Sequentially list conditions, if b) any, leading to the jcause,llsted: on lint a.- - DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. a 0. I FEMALE ❑'Not pregnatit within pa 4 year U- ❑ Pregnant at time of death T ❑ Not pregnant,;but pregnant within 42 days -... death El Not pregnant, but pr 43 days to 1 year before death ❑ Unkn rpg ow if p am wit the past year 22a. DATE OF INJURY (Mo., Day, Yr.) E 4, 22b. TIME OF INJURY 22d. INJURY AT WORK? :. ♦° ] YES NO 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. X 25. 0I1) TOBA ❑ YES USE CONTRIBUTE TO THE DEATH? NO ❑ PROBABLY ❑ UNKNOWN 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22e. DESCRIBE HOW INJURY OCCURRED CITY /TOWN DATE 07CE'S.H ratt.,Da_y,Y) a • August 15,;2017 C 0. w O $ 23b. PATE SIGNED (Mo., Day, Yr.) September 7, 2017 23c. TIME OF DEATH 11:47 PM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causets) stated. (Signature and Title) Ryan Ramaekers, MD 28a. REGISTRAR'S SIGNATURE 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ pedestrian 0 Other.(SPecify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) STATE 24d. TIME PRONOUNCED DEAD 24a. DATE SIGNED (Mo.. Day, Yr.) 1 c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO ZIP CODE 24e. On the basis of examination and /or investiga ion, in my opinion death occurred at. the time, date and place and due to the causes) stated.'(Signature and Tale) 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan Ramaekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ 'ES ❑ NO 28b. DATE FILED BY REGISTRAR Mo., Day, Yr.) September 7, 2017 201707936 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES