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<br />WHEN > THIS #' COPY CARRIES THE RAISED SEM. 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 />DATE OF ISSUANCE
<br />3/4/2020
<br />LINCOLN, NEBRASKA
<br />IFINIIMIIII
<br />DECEDENTS-NAME (first, Middle, Last, Suffix)
<br />I
<br />202100144
<br />SARAH BOHNENKAMP
<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 />Donna Jean Schmidt fff
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH I5a. AGE ,Last Birthday UNOER 1 YEAR
<br />Lincoln, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505.44-8376
<br />�gg
<br />as
<br />sS
<br />B
<br />/lb.'FACILITY-NAME (If not Institution, give street and number)
<br />512 East 11th Street
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />Sb. COUNTY
<br />Hall
<br />i DAYS
<br />Be. PLACE OF DEATH
<br />HOSPITAL ❑Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Female
<br />16 06732
<br />3. DATE OF DEATH undo.. flay, Yr.)
<br />September 12,`2016
<br />Sc. UNDER 1 DAY S. DATE OF BIRTH (Mo., Day,Yr.)
<br />ISCURF :1;S.
<br />iAugLIC: 93Z
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Homs
<br />0 Other(Specly)
<br />Sd. COUNTY OF DEATH
<br />Hall
<br />❑ Hospice Faculty'
<br />lid STREET AND NUMBER
<br />512 East 11th Street
<br />Ile. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />as. woos cITY uMrrs
<br />®'YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Mauled, but separated 0 Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Norman LeRoy Schmidt
<br />11. FATHER'S.NAME (First, MIdde, Last, Suffix)
<br />Dewey Coots
<br />112. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />tva Ferrier
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Jeanne Allen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />IS. METHOD OF DISPOSITION
<br />)Budd ❑Donation
<br />CremetIon 0 Entombment
<br />0 Removal' 0 Other (Specify)
<br />1Sa. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />15d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />1454
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />te. PART L Enter ant cr:.M of events- diseases, Inhalem, or compricatbr ince[ ohecdy .:awed ant ,.sem. LAO vo.1 enter nlm,x14 morns sKn as pre at ccreat,
<br />reepbatory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addtnsnsl lines N necessary.
<br />IMMEDIATE CAUSE:
<br />14 DlATE muss (Final a) Organ Failure
<br />disease or condition resulting
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially Net conditions, if b) Alzheimers
<br />any, lading toms cans* aatad
<br />an line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Ener Me UNDERL INO CAU3tE C)
<br />(Menne or injury that initiated
<br />the events resulting M dead') DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />111. PARTS. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />20. IF FEMALE:,
<br />❑: Net pregnant *thinnest year
<br />❑' Prepnenntat 11eu of Magi'
<br />Not pregnant, but pregnant within 42 days of Math
<br />0 Not pregnant, tut pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the put year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />0 Accident 0 lending invaetlgution
<br />❑ suicide 0 Could not be determined
<br />21b IF TRANSPORTATION INJURY
<br />P*Nenger
<br />0 Pedestrian
<br />❑ Otter (speaBy)
<br />16e. DATE (Mo., Day, Yr.)
<br />September 11, 2016
<br />STATE
<br />Nebraska
<br />17b. 22p Cads
<br />68801
<br />APPROXIuAATE 1I: i ertVAL
<br />onset to death
<br />Days
<br />onset to death
<br />Years
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO;
<br />21e. WAS AN AUTOPSY PERF(RMED?
<br />0 YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF"DEATH?
<br />❑ YES ❑ NO .. ,
<br />22a. DA 'rla OF INJURY (Mos; Day, Yr.)
<br />b
<br />22d. INJURY AT WORK?
<br />❑ YES ❑NQ::.
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, lam, street, factory, office building, construction site, fits. )Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />� P
<br />iLr, r:J.iM t.J,v w. ur,11.;:tt" ..,,tEL , .F i3L,btse.r., w: ... .,.
<br />a
<br />OS
<br />0.
<br />I
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23e. TIME OF DEATH
<br />3d. Tette best army knowledge, death occurred at the tins, deli and place
<br />and due to the saute(') stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES El NO ❑ PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />September 14, 2016
<br />24b. TIME OF DEATH
<br />03:30 PM
<br />CCDC
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />September 12. 2016
<br />24d. TIME PRONOUNCED DEAD
<br />04:00 PM
<br />SM. ton the basis of examination andror Invsetlgrdbn, in my opinion daithoOdinyid et
<br />fin tone, data and place and due to the causes) stated. (Signature 404 :2111e)
<br />Danielle L. Myers, Hall Deputy County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES i3d NO
<br />21b. WAS CONSENT GRANTED?
<br />Not Applicable If 2Sa Is NO ❑ YES
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Danielle L. Myers, Hall Deputy County Attorney 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />ito
<br />i
<br />211s REGISTRAR'S SIGNATURE - cad dns"
<br />❑N?
<br />2Sb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 21, 2016
<br />
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