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REV (8/13) <br />YSTATE OF NEW MEXICO`; <br />New Mexico Vital Records and Health Statistics <br />State of New Mexico <br />United States of America <br />No.4257792 <br />DECEDENTS LEGAL NAME <br />«<Dwain Eugene Schroeder»> <br />IF FEMALE, MAIDEN NAME <br />«<»> <br />DATE OF DEATH <br />September 12, 2018 <br />TIME OF DEATH <br />AM <br />02:30 <br />SEX <br />Male <br />SOCIAL SECURITY NUMBER <br />507-50-0367 <br />In PM K1 <br />MARITAL STATUS <br />> Married <br />SURVIVING SPOUSE - If wife, maiden name <br />«<Melissa Sandate»> <br />PATE OF BIRTH <br />July 18, 1941 <br />BIRTH PLACE <br />Dorchester, Nebraska <br />SERVED IN U.S. ARMED FORCES <br />Yes f / No • <br />DECEDENTS RACE <br />)White <br />TRIBE <br />«<»> <br />HISPANIC <br />Yes • No ji <br />DECEDENTS RESIDENCE COUNTY <br />3 <br />11Hall <br />DECEDENTS RESIDENCE STATE <br />Nebraska <br />""" <br />tOTHER'S FULL MAIDEN NAME <br />«<Tressie Viola Unknown»> <br />FATHER'S FULL NAME <br />«<William Ernest Schroeder»> <br />METHOD OF DISPOSITION <br />0 Burial 0 Donation 0 Removal from State <br />I4 Cremation 0 Entombment 0 Other(Specify): «<»> <br />DISPOSITION LOCATION <br />New Mexico Mortuary Service <br />i <br />.FUNERAL SERVICE FACILITY <br />Riverside Funeral Home of Santa Fe <br />COUNTY <br />Santa <br />OF DEATH <br />Fe <br />LACE OF DEATH <br />c«<c�, <br />St. Vincent Regional Medical Center <br />TYPE OF PLACE <br />Hospital -Inpatient <br />NAME OF PERSON CERTIFYING CAUSE OF DEATH <br />cc�� <br />ci <br />V akr <br />-.MANNER OF ® Natural 0 Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending <br />DEATH Investigation <br />i <br />AUSE OF DEATH <br />°ART I. Events such as diseases, injuries, or complications that directly caused the death. <br />i <br />0 <br />a. Acute respiratory failure <br />N <br />4 b. Severe sepsis <br />1 <br />c. Acute kidney failure <br />• <br />d. Urinary retention <br />PART II. Other significant conditions contributing to death. <br />«<»> <br />File Number: <br />File Date: <br />Order Number: <br />2018-012690 �/ <br />September 25, 2018 cg?efee //r2��) State Registrar <br />20181000314 <br />WARNING: IT IS ILLEGAL TO ALTER, COPY OR COUNTERFEIT THIS CERTIFICATE. <br />ADVERTENCIA: ES (LEGAL ATERAR, COPIAR 0 FALSIIFICAR ESTE CERTIFICADO. <br />CERTIFIED COPY OF VITAL RECORD <br />This is a true and exact reproduction of all or part of the document <br />officially registered and tiled with the New Mexico Bureau of <br />Vital Records and Health Statistics, Department of Health. <br />DATE ISSUEcOCt-02-2018 <br />