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STATE OF NEBRASKA
<br />WHEN THIS '<'COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR v T�IL EpgfiaD��S
<br />DATE OF ISSUANCE (vr U `�
<br />2/7/2017
<br />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Pauline Louella Schroeder
<br />ART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ye tricy fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Neoplasm Of The Digestive System
<br />disease or condition resulting
<br />APPROXIMATEINTERVA
<br />onset to death
<br />05 -22 -2009
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Kearney, Nebraska
<br />U
<br />K 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand .Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />E 9d. STREET AND NUMBER
<br />2415 W. Anna
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />85
<br />7. SOCIAL SECURITY NUMBER
<br />505 - 22.8792
<br />8b. FACILITY NAME (If not Institution, give street and number)
<br />Park Place -A Golden Living Center
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER E Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />❑ Hospice Facility
<br />9b. COUNTY
<br />Hall
<br />Oa: MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Harold Kerwood
<br />E I 13. EVER IN U.S. ARMED FORCES?
<br />3 (Yes, No or L11210(4(1
<br />9c. CITY OR TOWN
<br />Grand Island
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Eli Schroeder
<br />12. MOTHER'S -NAME (First, Middle,
<br />Mary Margaret Devall
<br />Give dates of service if Yes. 14a. INFORMANT -NAME
<br />Eli Schroeder
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />0
<br />1--
<br />1 5. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER-SIGNATURE
<br />Daniel D Naranio
<br />16b. LICENSE NO.
<br />1071
<br />16c. DATE (Mo , Day, Yr.)
<br />June 13, 2009
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Shelton Cemetery
<br />la. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island. Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />deatht
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />SequeMiany fist comets) 8 . . i
<br />any, loading to the cause fisted
<br />on iinea
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING. CAUSE c)
<br />(disease Ot injury that Initiated
<br />at ngln death)
<br />the events resu
<br />t.AST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />la 0. IF:FEMALE:
<br />❑ Not pregnant within past year
<br />U ❑ Pregnant at time of death
<br />❑ Not pregnant but pregnant within 42 days of death
<br />1.1 ❑ Not pregnant, but pregnant 41 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />0
<br />2 22d. INJURY AY AWORK?
<br />DYES . ❑ Na
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />I 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />A f ? June 9, 2009
<br />SI 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />1 b z June 12, 2009 01:03 PM
<br />u 4 0 3d. To the best of my knowledge, death Occurred at the time, date and place
<br />8 o and due to the cause(s) stated. (Signature and Title)
<br />o
<br />Douglas Herbek, MD
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ COuId not be determined
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />CITY/TOWN
<br />Ea
<br />5b. UNDER 1 YEAR
<br />M OS.
<br />DAYS
<br />HOURS
<br />9e. APT. NO.
<br />CITY /TOWN
<br />Shelton
<br />21b. IF TRANSPORTATION
<br />0 Driver /Operator
<br />❑ Passenger
<br />Pedestrian
<br />0 Other (Specify)
<br />INJURY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES O NO ❑ PROBABLY ❑ UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Douglas I erbek, MD, 2444 W. Faidley Avenue Grand Island, Nebraska, 68803
<br />28a, REGISTRAR'S SIGNATURE 13-
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MINS.
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9f. ZIP CODE
<br />68803
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 9, 2009
<br />6. DATE OF BIRTH (Mo., pay, •Yr.)
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />STATE
<br />Maiden Surname)
<br />24b. TIME OF DEATH
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES 21 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and /or investigation, In my . opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES ❑
<br />28b. DATE FILED BY REGISTRAR (Mo.,'Day, Yr.)
<br />June 15, 2009
<br />STATE OF NEBRASKA - DEPARTMENT 01: HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />
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