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tit V" s, rl ill x A Q 1��>taec - - - kt....,w a te- _ _ WHEN THIS ''COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A 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 1/18/2019 LINCOLN, NEBRASKA 201.90350i ASSISRUSSELL T ANT STATEDSLER REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Pursuant to section :30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ellen Lorraine Schritt 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) January 3, 2019 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Portland, Oregon (Yrs.) 77 MOS. DAYS HOURS MINS. January 9, 1941 7. SOCIAL SECURITY NUMBER 506-50-1345 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) - 2316 Park Dr. ❑ ER/Outpatient ®Decedent's Home 0 DOA 0 Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY DR TOWN Grand Island 9d. STREET AND NUMBER 2316 Park Dr. 9e. APT. NO. 9f. ZIP CODE 68801 9g.INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑;Married, but separated ® Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 1Mllliam Fred Schritt 11. FATHER'S•NAME (First, Middle, Last, Suffix) John Thorpe 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Althea Hisel 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Lisa Olson 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo„ Day, Yr.) January 7, 2019 ® Cremation 0 Entombment ❑_Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b, Zip Code 68801 CAUSE OF DEATH (See, instructions and examples) 16. PART 1. Enter the chain of events -diseases, injuries, or complications -that directly caused the death. DO NOT eller terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEuiATb CAubE (rine, .i Recurrent Partial Smell Bowel L)Ostruction, vveignt Loss I-rogressive uecilne disease or condition resulting onset to death Years in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, it " b)Ad hesions any, leading to the: cause listed on Ime a. onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease orinjury .that initiated onset to death the events resuRin9 in death( DUE TO, OR AS A CONSEQUENCE OF: LAST; d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Obstructive Lung Disease Severe In Nature, Hypertension, Renal Insufficiency 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 20.1F FEMALE: 0 Not pregnant within past year ❑Pregnant at time of death 21a. MANNER OF DEATH E Natural ❑ Homicide 0 Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO ❑ Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ unknown if pregnant within the past year 0 Suicide 0 Could not be determined 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT ❑ YES WORK? ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by 7f MEDICAL CERTIFIER ONLY 23a. UA:YL OF DEATH (Mo., Day, Yr.) - January 3, 2019 To be completed by -... CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. (ATE SIGNED (Nio., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 7, 2019 23c. TIME OF DEATH 10:00 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jane A. McDonald, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25.`010 TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES 0 NO 0 PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES E NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jane A. McDonald, MD, 800 N Alpha Street, G and Island, Nebraska, 68803 28a, REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 11, 2019