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e' 04,.a °o alr, " , ammo 2 WHEN THIS f` 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 OF ISSUANCE 9/21/2017 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH re 1. DECEDENTS-NAME (First, Middle, Last, Suffix) Eric Ronnie Schmit 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lincoln, Nebraska 7. SOCIAL SECURITY NUMBER 507 -11 -3168 543. FACILITY -NAME (If not Institution, give street and number) 104 W. 20th St. re 8c. CITY OR TOWN OF DEATH (Include Zip Code) J - Grand 'vane 68801 LL 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No or Unit.) No 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation 0 Cremation ❑ Entombment ❑.Removal _:❑ Other (Specify) 5a. AGE - Last Birthday (Yrs.) 36 5b. UNDER 1 YEAR DAYS MOS. 8a. PLACE OF DEATH HOSPITAL 0 Inpatient ❑ ER/Outpatient ❑ DOA 9d. STREET AND NUMBER 104 W. 20th St. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC E Decedents Home ❑ Other (Specify) I 8d. COUNTY OF DEATH Hall - 8c. CITY OR TOWN Grand! Island 9e. APT. NO. 9f. ZIP CODE 68801 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Bethany Sue Nelson 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ronnie Schmit 14a. INFORMANT -NAME. Bethany Sue Schmit 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Patricia Delsing 16a. EMBALMER-SIGNATURE Katie M. Smydra 16b. 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 3. DATE OF DEATH (Mo., Day, Yr.) August 15, 2017 6. DATE OF BIRTH (MG. Day, Yr,) September 27, 1980 ❑ Hospice Facility 9g. INSIDE CITY<LIMITS ® YES ❑ NO 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) le. PART t. Enter the chain of events- - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line; Add additional lines if necessary. _ IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Sarcoma of Right Leg, Metastatic onset to dea disease or condition resulting death) Sequentially list copditions, if • any, leading to the ]Seuae listed Enter the UNDERLYING CAUSE 4diseeeeo, mlury that initiated. the events resulting in death) LAST: 22a. DATE OF INJURY (Mo., Day, Yr.) 22d..INJURY AT WORK:, ❑ YI:S ❑ NO S< Ryan Ramaekers, MD EGISTRAR'S SIGNATURE DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 0. IF: FEMALE: ❑ Not pregnantaithitt past year 0 Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ tltrknowd if pregnant wittd t the past year i. Yr. 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. rt a August 15,;2017 �23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH September 7, 2017 11:47 PM 23d. To the best of my knowledge, death occurred at the time, date and place and due to the tassels) stated, (Signature and Title) 2017079 STANLEY T T R E ` I� j ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation Suicide ❑ Could not be determined 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) CITY/TOWN 7..4_. DA1'° S!GNED fyo.. nay, Yr.) CApti APPROXIMATE INTERVAL onset to death 5 Yes ath STATE 4c. PRONOUNCED DEAD (Mo., Day, Yr.) September 7, 2017 onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES •®NO 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? 0 Orer/Operator ❑ YES E NO ❑ Passenger ❑ pedestrian other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE.. TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO I 24b. TIME OF DEATH 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN :ONSIDERED? ❑ YES E] NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan Ra(7)aekers, MD, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803 , ZIP CODE 24d. TIME PRONOUNCED D 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 tassels) stated (Signature and Title) 26b. WAS CONSENT GRAN „-r? Not Applicable if 26a is NO ❑ YES ❑ NO CD 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) (D CTI CD C