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<br />WHEN THIS I! 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 A,
<br />I /
<br />DATE OF ISSUANCE RUSSELL FOSLER
<br />1/14/2019
<br />LINCOLN, NEBRASKA
<br />v
<br />E.
<br />m
<br />4,
<br />v
<br />d.
<br />202100144
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Norman LeRoy Schmidt
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 11, 2018
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Beatrice, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-42-7976
<br />5a AGE - Last Birthday 15b. UNDER 1 YEAR
<br />lyre.)
<br />83
<br />Sb. FACILITY -NAME (ff notInstitution, give street and number)
<br />CHI Health. St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Z p Code)
<br />Gland island 68803
<br />99. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Sc. UNDER 1 DAY
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />0 ER(Outpatient
<br />❑ DOA
<br />Sc. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo: Day, Yr.).
<br />May 7, 1935
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. ^OUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9d. STREET AND NUMBER
<br />3119 W. Faidley Ave
<br />19a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑!Married, but separated. E Widowed 0 Divorced 0 Unknown
<br />/9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g: INSIDE CITY.LIMITS
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First. Middle, Last,
<br />Donna Jean Flint
<br />Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Otto Schmidt
<br />12. MOTHER'S -NAME (First, Middle,
<br />Bertha Weber
<br />Maiden Surname)
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yea, NO, Or Unit.) No
<br />14a. INFORMANT -NAME
<br />Jeanne Allen
<br />14b. RELATIONSHIP; TO DECEDENT
<br />Niece
<br />15. METHOD OF DISPOSITION
<br />®Burial ] Donation
<br />❑ Cremation 0 Entombment
<br />❑Removal 0 Other{Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />16b. LICENSE NO.
<br />1454
<br />16c. DATE (Mo., Day, Yr.)
<br />December 15, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />�17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17b. zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions apd examples)
<br />11. PART L Enter** chain elements -diseases, injuries, or complications -Mat directly caused the taste. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, er ventricular abriNation without showing the etiology. CO NOT ABBREVIATE. Enter only ono esuse on a line. Add additional lines It necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Hypoxia
<br />disease or contrition resuaing
<br />Sequentially list conditions H
<br />any reading to the cause listed'.
<br />Enter the UNDERLYING CAUSE
<br />(dissaas of iNury t art initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Severe Sepsis With Septic Shock
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />4 Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Acute Intestional Obstruction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />10 Days
<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 />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />0 Nat poignant, but pregnant within 42 days of death
<br />© Not pregnant but pra9nent 43 days to 1 year before death
<br />❑ unknown H pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />]YES ONO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />21a. MANNER OF DEATH
<br />E Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could net be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES E NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ENO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?i:
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />I23a. DATE OP DEATH (Mo., Day, Yr.)
<br />e r ucw '1,'1 wiv
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />5 - December 12, 2018
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />03:32 PM
<br />2d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Otte)
<br />2 Traci: Penner, APRN
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES E NO 0 PROBABLY 0 UNKNOWN
<br />STATE ZIP CODE
<br />24a. DATE SIGNED (Mo., Day, Yr.) 124b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the cause(e) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED?
<br />DYES NO
<br />28b. WAS CONSENT GRANTED? I'
<br />Not Applicable If 28a is NO 0 YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Traci Penner, APRN, 2621 W Faidley Avenue, Grand Island, Nebraskan 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />oird40-4Z---
<br />28b. DATE FILED BY REGISTRAR (Ma,, Day, Yr.)
<br />December 20, 2018
<br />
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