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<br />STATE OF NEBRASKA
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<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 VITAL RECORDS
<br />2017088 +1
<br />DATE OF ISSUANCE
<br />4/25/2016
<br />LINCOLN NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />18. PART 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 />regpirat6ty arrest, or vents -Ci ler 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) Respiratory Failure
<br />disease or condition resulting
<br />awl
<br />.4
<br />0.
<br /><1<
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Karen Kay Schneider
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Broken Bow, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505 -80- 2278
<br />813. FACILITY -NAME fir not Institution, give street and number)
<br />VVedgewood Care Center
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />59
<br />Si,. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9d. STREET AND NUMBER
<br />4029 Sandalwood Drive
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated. ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Leonard Peterson
<br />13. EVER IN U.S ARMED: FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) No
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER - SIGNATURE
<br />Chris McCoy
<br />9e. APT. NO.
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 18, 2016
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />January 31, 1957
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER ® Nursing Home1LTC ❑ Hospice Facility
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITi! OR TOWN
<br />Grand Island
<br />9f. ZIP CODE
<br />68803
<br />9 CITY UM {TS'
<br />® YES ❑ NO
<br />10b, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Thomas Schneider'.
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Bonnie Ferguson
<br />14a. INFORMANT- NAME
<br />Thomas Schneider
<br />16b. LICENSE NO.
<br />1191
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home. 1123 W. 2nd, Grand Island. Nebraska
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day,, Yr.)
<br />April 21, 2016
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b, Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />APPROXfMATEINTERVAL,
<br />onset to death
<br />> 24 Hours
<br />2
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the: cause (stfd
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Metastatic Adenocarcinoma Of The Colon
<br />Onset to death
<br />10 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to death
<br />Enter the UNDERLYING CAUSE
<br />(disease or Injury initiated:
<br />the eventsresuning in death)
<br />LAST::
<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 I.
<br />20. IF FEMALE
<br />Ea Not pregnant *thinnest year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant; tut pregnant within 42 days of death
<br />❑ Not pvegnaft, but pregnant:43 days to 1 year before death
<br />❑ tjnknown if pregnant wdhitl the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />:2d. INJURY. AT WORK?
<br />D YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />!" April 18, 2016 01:40 AM
<br />0 � 3d. To the best of my knowledge, death occurred at the time, date and place
<br />A 52 and due to the cause(s) stated. (Signature and Title)
<br />0
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 18, 2116
<br />Jenr;ifer L. Brown, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES Ed NO ❑ PROBABLY ❑ UNKNOWN
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />CITY/TOWN
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver /Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR SSUE +•
<br />❑ YES 7 NO
<br />ATION BE
<br />EN CONSIDERED?
<br />28a.REGISTRARSSIGNATURE 6 o
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED ? s:
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH ?. •
<br />0 YES ❑NQ
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<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 ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 6(3803
<br />28b. DATE FILED BY REGISTRAR (MO.,'Day, Yr.)
<br />April 19, 2016
<br />
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