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�i�Dtilu��l$GS,�,r��,»z��t11�1�(lllse): r�arrt��M ��r�rAYt4!!5�rae� .i' �rtYtYd re tAttt4yGj)'Sifdddta._ /.rurAty „'+ Fid {r:;..4Wdild :.-.±-:�•,�.�. .-.<�...:.. ....- rttllillfll� p hill i11HG16:,,.;;IiNlu,�i((�g iyyrryja?4�Q� lliiliigl� 5 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 3/8/2021 LINCOLN, NEBRASKA 202102499 ja g y SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 21 02871 W al to m, 1. DECEDENTS -NAME ;First, Middle, Last, Suffix) Steve Herman Schmidt 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) February 28, 2021 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Bancroft, Nebraska 7, SOCIAL SECURITY NUMBER 505»36-8199 5a. AGE - Last Birthday (Yrs.) 8b. FACILITY-NAME(If not Institution, give street and number) Grand Island Lakeview Care & Rehabilitation Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 91 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient 0 ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island HOURS MINS. 6. DATE OF BIRTH (Mo., Day, Yr.) July 18, 1929,,.;, OTHER ® Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Hall 9d. STREET AND NUMBER 2605 South Stuhr Road 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS YES ❑ Na 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Clarlene Kiser 11. FATHER'S -NAME (First, Middle, Last, Suffix) Emil Schmidt l12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lila Schmidt 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) No 14a. INFORMANT -NAME Clarlene Schmidt 14b. RELATIONSHIP TO DECEDENT' Spouse 15. METHOD OF DISPOSITION Burial ❑ Donation 0 Cremation ❑ Entombment ❑ Removal 0 Other (Specify) 16a. EMBALMER -SIGNATURE Gwen K. Hyronemus 16b. LICENSE NO. 1448 16c. DATE (Mo., Day, Yr.) March 5 2021 16d. CEMETERY, CREMATORY OR OTHER LOCATION Mount Hope Cemetery CITY / TOWN West Point STATE Nebraska 17a FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Horne, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801;; CAUSE OF DEATH (See instructions and examples) 111. PART I. Enter the chain of event- -0i , Injuries, or complications4hat directly caused the death. DO NOT enter terminal everts such u cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Alzheimer's Dementia IMMEDIATE CAUSE (Final disease or condition resulting In death) Sequentially list conditions, if any, leading to the cause listed on line a. Enter ttie UNDER YINOCA0SE (disease or Injury that initiated the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: b) APPROXIMATE INTERVAL onset to death Years onset to death DUE TO, OR AS A CONSEQUENCE OF: c) onset 30 death DUE TO, OR AS A CONSEQUENCE OF: 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. 19. WAS MEDICAL. EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death Net pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown If pregnant within the past year 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator 0 Passenger Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 14 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 NO 22e, 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 WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22t.LOCATION'OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE e 0 2, N a 0 0. 23a. DATE OF DEATH (Mo., Day, Yr.) February 28, 2021 23b. DATE SIGNED (Mo., Day, Yr.) March 2, 2021 23c. TIME OF DEATH 08:40 AM 3d. To the beet of my knowledge, death occurred at the time, date and place and due to the'cause(s) stated. (Signature and Title) Richard Fruehling, MD 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 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. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES Ei NO 0 PROBABLY 0 UNKNOWN 27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Richard Fruehling, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES', 0 NO 28a. REGISTRAR'S SIGNATUREi L o�za� �aic t,'yc 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I March 3, 2021 '1 Q CO