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a <br />C <br />n <br />u <br />!)Q. _ c m N rT1 <br />cv <br />rn n �E <br />PIZ <br />� f Ott <br />©Q. ` N Q ^1 O � <br />rM <br />M _ —fl LSD O <br />c� CD <br />tD 3 r ..� <br />r <br />s i cr) t W <br />ca <br />W <br />�S so <br />N <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE 01TH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICSWTION, WHICH is <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. , <br />DATE OF ISSUANCE ` <br />JUL 13 2001 200107317 ASSISMNrSTATEAEO /STRAl.2 <br />LINCOLN, NEBRASKA HEALTH AND HU 1ftN $ERMES SYSTEM <br />SPATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVjgE$.i?iN1ANC Al SUPI'}3RT <br />VITAL STA'T'ISTICS - V 1 07 `t `t <br />CERTIFICATE OF DEATH - <br />�I DEitUENT NAME RRST MIDDLE LAST <br />2 SE %- <br />3. DATE OF DEATH tMOnlh Oat Yeah <br />Samuel Gottlieb Schleicher <br />Male <br />July 3,2001 <br />it <br />(Ages 10 -541 Yes No <br />Yes R No Yes No- <br />GTY AND STATE OF BIRTH ill nctm USA name country) <br />Sa. AGE Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY - <br />6. DATE OF BIRTH (Month. Day year) <br />Grand Island Nebraska <br />Y's 72 <br />September 8, 1928 <br />5b MOB DAYS <br />Sc HOURS MINS <br />7 SOCIAL SECURTIY NUMBER <br />8a PLACE OF DEATH <br />506 -26 -7871 <br />HOSPITAL ❑ Inpdtienl OTHER ® Nursing Hor,-.M—VA <br />t <br />ER Outpatient Restlence <br />Bb FACILITY Name 111 not ovd hon. grve street and number) <br />.VA Nebraska - Western Iowa Health Care. <br />° °A ❑ °'rte " "� "" <br />8c CnY TOWN OR LOCATION OF DEATH <br />Btl INSIDE CITY LIMITS <br />Be COUNTY OF DEATH <br />Grand Island <br />Yes �j No <br />Hall <br />9a PFSOENCE - STATE <br />9 COUNTY <br />9c CITY. TOWN OR LOCATION <br />9d STREET AND NUMBER ilnctuding Zip Code] <br />9e INSIDE CITY L.i MITS <br />Nebraska <br />Hall <br />Grand Island <br />2232 West 11th Street <br />Y °sRj N0 <br />10 RACE - le g.. White Black Amencan Indian <br />11. ANCESTRY le g. Italian. Mexican. German, elO <br />12. ® MARRIED ❑ WIDOWED <br />13 NAME OF SPOUSE l/l wile give maiden name) <br />etc.)'Soectyl T7�,, <br />W hi to <br />ISpealyl /�� <br />German <br />NEVER DIVORCED <br />MARRIED <br />pats Hildebrand <br />14a USUAL OCCUPATION )Grve kind of work done during most <br />14b KIND OF BUSINESS INDUSTRY <br />15 EDUCATION ISpec,fy only highest grade completed) <br />__ -- <br />Elementary or Secondary 10 12) College 1 4 or S <br />10 ade <br />ol working Me even d reh,edii <br />Maintenance <br />City Em to ee <br />16 FATHER NAME FIRST MIDDLE LAST <br />" MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Gottleib . Schleicher <br />Marie Heimbuch <br />18 WAS DECEASED EVER w U.S. ARMED FORCES? Army <br />19a INFORMANT - NAME <br />Ives no nr tin. III yes grve war and dales of services) 11L711 <br />30.b WAS CONSENT GRANTED' <br />Yes 4 -9 -1947 to 10 -09 -1948 <br />Patsv Schleicher _ <br />19b INFORMANT MAILING ADDRESS ISTREET OR R.F.D NO CITY OR TOWN. STATE. ZIP) <br />2232 West 11th Street Grand Island NE <br />20 EMBALMER SIGNATURE 8 LICENSE NO <br />21a METHOD OF DISPOSITION <br />21b. DATE 21c CEMETERY OR CREMATORY NAME <br />Not. Embalmed <br />El Burial Removal <br />July 314 .2001 entral NE Cremation v' <br />22a FUNERAL HOME NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />A fel- Butler - Geddes <br />®Cremation 11 Duration <br />Gibbon, Nebraska _ <br />22b FUNERAL HOME ADDRESS (STREET OR R D NO. CITY OR TOWN. STATE. ZIP) <br />West Second Street Grand Island, Nebraska 68801_ _ <br />_1123 <br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la; Ibl. AND fc)l Interval between ons�31 n ,r; <br />PART Cardiorespiratory Arrest <br />1 <br />7 <br />TA <br />t]Dt 7U UHAJAl,V "'t"UtNUI, r Hypertension <br />Ibl Cerebrovascular Accident,Coronary Artery Disease ,Malnutrition <br />DUE TO OR AS A CONSEOUENCE OF <br />Hypertension <br />0— ..1.,.- ,l ., A--4A--+- r- A—t-- • T)i -- Ado —f-r4 ti nn <br />Interval netween onset ano -air, <br />OTHER SIGNIFICANT CONDITIONS - Cogd,hons contributing to the death but not related PART <br />IF FEMALE. WAS TRER A <br />24 AUTOPSY 25 WAS CASE REFERRED 70 MEDICAL. <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS' <br />EXAMINER OR CORONER' <br />it <br />(Ages 10 -541 Yes No <br />Yes R No Yes No- <br />?6a <br />26b DATE OF INJURY /MO. Day. Yr.) <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Undete m red <br />I <br />u„ rate Pundiny <br />26e INJURY AT WORK <br />261 PLACE OF INJURY AI home. farm street. factory <br />26g LOCATION STREET OR R F D NO Cl T OR TOWN STATE.- <br />Norn"de InveStigdlion <br />❑ <br />office building. etc 'Specify) <br />Yes No <br />27a DATF OF DEATH IMO Day vr) <br />28a DATE SIGNED IMO Day Yr I <br />28b TIME OF DEATH <br />�L July 3,2001 <br /><w <br />. <br />, <br />M.. <br />_ <br />n . 27b DATE SIGNED IMO Day Y,) <br />27c TIME OF DEATH <br />28c PRONOUNCED DEAD (Mo Day, Yr <br />28d. PRONOUNCED DEAD /NOUc <br />3,2001 <br />5:20 a.m. <br />z <br />g=ao <br />cJ ..luly <br />M <br />° ¢ ° <br />M- <br />276 io the best of my knowledge death occurred at the time. date and place and due to the <br />28e On the basis of examination and or investigation, in my opinion death occurred at <br />causels) stated. <br />the time, date and place and due to the causelsl stated. <br />I S, nature antl Title) ► <br />(St nature and TrIel 1, <br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATHS <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED <br />30.b WAS CONSENT GRANTED' <br />YES ❑ NO UNKNOWN <br />"AN, <br />YES ® IN <br />YES a NO <br />31 NAMF AND ADDRESS OF CERTIFIER IPHYSII�YC-'I <br />CORONERS PHYSICIAN OR COUNTY ATTORNEY /Type or Pnnll <br />Karuna S. Gaddam MD VA Nebraska- tiIestern Iowa HCS 2201 North Broadwell Grand Island <br />32a REGISTRAR <br />32b DATE FILED BY REGISTRAR IMO. Day Yr] <br />E <br />