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b STATE OF NEBRASKA - ,,. tz,m varyr. WHEN THIS . COPY CARRIES THE RAISED SEAL ` OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE iA 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 1/17/2017 LINCOLN NEBRASKA 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Steven Husen, MD 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 Yes El NO ❑ PROBABLY ❑ UNKNOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Steven H,.usen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska 28a. REGISTRAR! SfGNATURE J6 a 68803 201708178 ASSISTANT S ATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 24e. On the basis of examination and /or investigation, in my opinion de ar,ad at the time, date and place and due to the cause(s) stated. (Signature and 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Eli Henry Schroeder 4. CITY AHD: STATE OR TERR ITORY, OR FOREIGN COUNTRY OF BIRTH Wood River., Nebraska 7. SOCIAL SECURITY NUMBER 721 -14 -2049 1. FACILITY -NAME (If not Institution, give street and number) ar Good Samaritan Society -Wood River 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River 68883. 9a. RESIDENCE -STATE COUNTY Nebraska 19b. Hall W 9d, STREET AND NUMBER >. 1401 East Street d iv u... W U y 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑Married but separated' . ® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) William Schroeder 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Mae Rosanna Baker EVER 1N U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link.) NO E 15. METHOD OF [11SPOSITIQN ® Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Remaval ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Laurie D. Sheffield 16d. CEMETERY, CREMATORY OR OTHER LOCATION Shelton Cemetery CITY / TOWN Shelton STATE Nebraska 7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) 1a. PART 1. 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 no a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Chronic Systolic Congestive Heart Failure, ischemic Cardiomyopthay disease or condition resulting APPROXIMATEINTERVAL 6 Months in? death) egeentially list conditions, tf any, feeding td the cause fisted on line a DUE TO, OR AS A CONSEQUENCE OF: b)Atherosclerotic Cardiovascular Dise onset todeath i:: >10 Years Enter the UNDERLYING CAUSE (disea orinlury ttlatini•el@d•. the ai!ents re m death) •: DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Chronic Cerebrovascular Disease,Chronic Kidney Disease Stage 3 20. IFaFE.MALE: • 0 Not pregnant within past year 0 Pregnant at time of death 0 Not pregnant but pregnant within 42 days of death ❑ Not pregnant, but pregnant43 days to 1 year before death ❑ t3rdtttown if pregna0twittditthe past year 22a. DATE OF INJURY (Mo,, Day, Yr.) 22d. jNJURY AT: NORK? ❑ YES ❑NO ia, DATE OF DEATH (Mo., Day, Yr.) January 5;2017 23b. DATE SIGNED (Mo., Day, Yr.) January 9 2017 22b. TIME OF INJURY 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 21a. MANNER OF DEATH Natural ❑ Hon eb:le ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 23c. TIME OF DEATH 06:50 AM 5a. AGE Last Birthday (Yrs.) 95 CtTY/TOWN 5b. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Wood River DAYS 9e. APT. NO. 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 9f. ZIP CODE 68883 14a. INFORMANT-NAME : John Schroeder 16b. LICENSE NO. 1397 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ pedestrian 0 other {Specify) STATE 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) January 5, 2017 July 19, 1921 6. DATE OF BIRTH (MO.,:Day, Yt.) 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA OTHER ® Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Hall 9g. INSIDE CITY LIMITS' ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Pauline Louelia Gustafson 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE (Mo., Day: Yr.)' January 10, 2017 17b. ZipCode 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES' j NO 21c. WAS AN AUTOPSY PERFORMED? '! ❑ YES l NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED ZIP CODE 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (MO„!Day, Yr.) January 10, 2017