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<br />HA03 6877 -5155
<br />200108663
<br />BILL G SCHAFFITZEL & BETTY J SCHAFFITZEL JT TEN
<br />WNW TM COPY CARRIES RES IM RAIISW SEAL OF THE NEBRASKA HEALTH =- _
<br />aSYSTEA4 R CERTOWS THE BELOW TO BE A- TRUE COPY OF THE ORIGINAL RffiC" "'A$
<br />THE NEBRASKA HEALTHAW,WMAN SERWCES..SYSjEM, VITAL STA178TICS SECROA4' I
<br />THE LEGAL DEPOSITI ORYP, R VITAL RECOR
<br />DATE OF ISSUANCE EVEREN CLEARING CORP. -
<br />MAR 131998
<br />VICE PNESiDeNT ASST 4" Q
<br />LINCOLN, NEBRASKA X 0 0 0 2 6 2 6 HEALTH AND _
<br />STA•tY &�� SERVICE
<br />HUMAN S F $IANC PPORT'
<br />ECC13 vrrA sr Tics
<br />CFRTTFTCATF- OF DRATH
<br />I. DECEDENT -NAME FIRST MIDDLE LAST
<br />2. SEX
<br />3. DATE DEATH /Month. Day Yearl
<br />21c CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />pp
<br />Bill George Schaffitzel
<br />Male
<br />Februar 25, 1998
<br />4. CITY AND STATE OF BIRTH /n not in USA.. name country/
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DII) E OF BIRTH tMonth. Day. Year/
<br />Republic, Missouri
<br />(Yrs.l
<br />74
<br />Aril 19, 1923
<br />Sb. MOS. DAYS
<br />Sc. HOURS MINS.
<br />7. SOCIAL SECURTIY NUMBER
<br />8a. PLACE OF DEATH
<br />486 -24 -4854
<br />HOSPITAL El Inpatient OTHER ® Nursing Home
<br />- - - --
<br />AUTOPSY
<br />❑ ER Outpatient ❑ Residence
<br />Bb. FACILITY - Nam (/ e /not insfiNUOn, give street and number)
<br />xx St. Francis Memorial Health Center
<br />❑ DOA ❑ Other (Specdy,
<br />XAMINER OR CORONER(
<br />(Ages
<br />1
<br />Ae. 711 T
<br />onammossmilo�
<br />-_
<br />26b. DATE OF INJURY /Md. Day. Yr)
<br />�-STATE sland
<br />r9a.RESIDENCE
<br />Yea Y No ❑
<br />Hall
<br />9b. COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Code,6 880 1
<br />LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />2010 W. Stolley Park Rd.
<br />7INSIDECITY
<br />27a. DATE OF DEATH /MO.. Day Yr.)
<br />No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY le g.. Italian. Mexican, German, etc)
<br />12.:U MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE Ill wee. give maiden namel
<br />mo.1 (Specify)
<br />White
<br />(Speciyl
<br />American
<br />NEVER DIVORCED 1-Betty
<br />171
<br />Davis
<br />M
<br />M ARRIED
<br />27b. DATE SIGNED /AID.. Day. Yr/
<br />m• 14a. USUAL OCCUPATION /Give kind of work done durn9 most
<br />rt awaking life, even ilrelired)
<br />14b. KIND OF BUSINESS INDUSTRY ' 1 O
<br />15. EDUCATION (Speciy only highest grade completed(
<br />Ele nl or Secondary 10 -12) College I1 -4 or 5.1
<br />MInown
<br />�W
<br />Dock Foreman /Truckdriver
<br />"1
<br />Trucking /Transport
<br />A
<br />16. FATHER -NAME FIRST MIDDLE LAST
<br />O
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />M
<br />Albert H. Schaffitzel
<br />Ao
<br />Dorthea NMN Harrington
<br />1& WAS DECEASED
<br />EVER IN U.S. ARMED FORCES?
<br />79a INFORMANT - NAME
<br />� (Vea no. a urw.l
<br />Yes
<br />II yes. ve wa. arts Gales a aervieesl
<br />1%13/43- 11/15/45
<br />IS nature and T t e
<br />M
<br />9
<br />S nature and Tid�1�
<br />Betty Schaffitzel
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />. rk m rt R. H, F.r .• � ..
<br />„„�yoA�; 2010 W. Stolley Park Rd., Grand Island, Ne. 68801
<br />n
<br />0 rt M W A
<br />p F, F,• m m M O m
<br />M rhtih O N M O. n ni
<br />rt m
<br />°¢ 77 f.h'om lilio
<br />p
<br />0 A7•��fhNrt
<br />MrtTz n F:0: �ry
<br />� N - It
<br />r7h'O ° 0 rp ,d O a
<br />A to pt
<br />D lb
<br />t m•e n �'�'rs rt
<br />yOY•O !naA NO
<br />C May y'. H' :IC tl
<br />20. EMBALMER - SIGNATURE A t ICENSE NO
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE
<br />21c CEMETERY OR CREMATORY NAME
<br />Not Embalmed
<br />❑Sunal ❑Removal
<br />Feb. 25, 1998
<br />Central Ne. Cremation Ser
<br />228. FUNERAL HOME - NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livingston- Sondermann F.H.
<br />OCramatkxt ❑Dona,ro
<br />Gibbon, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />601 N. Webb Road, Grand Island, Ne. 68803 -4050
<br />23. WMEQ04TE CAUSE )ENTER ONLY ONE USE PER LINE 01. AND 1c11 Interval between onsel and
<br />701al.
<br />PART
<br />}ddeeaat,
<br />�[ let ♦ /•, �O�i'��,�� %�,T/I iW
<br />Y
<br />DA T . R AS A CONSEOUENCE OF Interval between onset and death
<br />(b)
<br />. _ . I laaryal between O "and death
<br />(el �
<br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART
<br />III IF FEMALE. WAS THERE A
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />It PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />121
<br />y
<br />XAMINER OR CORONER(
<br />(Ages
<br />10 -54) Yes No M
<br />Yes No
<br />Yes No
<br />26a.
<br />26b. DATE OF INJURY /Md. Day. Yr)
<br />26, HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED ■ .
<br />F] Accident n Undetermined
<br />M
<br />�,
<br />M 0 b
<br />Strode Ej Pending
<br />26e. INJURY AT WORK
<br />26t. PLACE ?F. INJURY - At (tome. taint. street, fa r.
<br />o ice bu�ldlrg, etc /SpeciN)Y
<br />269. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE
<br />Hdnrdkie Investigation
<br />❑❑
<br />Yes No
<br />❑
<br />me
<br />di
<br />27a. DATE OF DEATH /MO.. Day Yr.)
<br />28a. DATE SIGNED (MO. Day Yr)
<br />28b TIME OF DEATH
<br />February 25, 1998'
<br />a
<br />M
<br />27b. DATE SIGNED /AID.. Day. Yr/
<br />727c, TIME OF DEATH
<br />PRONOUNCED DEAD /Mo.. Day, Yr/
<br />280. PRONOUNCED DEAD /HOUrI
<br />,-February, 25, 1998
<br />5:15 AM
<br />a = o
<br />o
<br />M
<br />$ .
<br />42: c°6
<br />5 Iu,�
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<br />27d. To the best of my kriDwIsogei., dealt occuffedr time. date and place and due to the
<br />�auselsl stated.
<br />28e. On Ire basis of examination and,or investigation, in my opinion death occurred at
<br />the time, dale and place and due to the causelsl stated.
<br />IS nature and T t e
<br />a
<br />S nature and Tid�1�
<br />2-9/. DID T OBACCO USE CON TE T T DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION
<br />N CONSIDERED?
<br />CONSENT GRANTED?
<br />1 ❑ YES ❑ UNKNOWN \
<br />/ ❑ YES
<br />NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI /Type a i
<br />John A Wagoner Jr MD, 00 Alpha Street. Grand Island Ne 68803
<br />32a. REGISTRAR
<br />x�
<br />320. DATE FILED By i1FC8Rj (.yp.. 19rdo
<br />V.
<br />
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