|
STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT O
<br />THE BELOW TO BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE;
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSIr.ORV
<br />DATE OF ISSUANCE
<br />14 200 20210579,
<br />OCT
<br />'`rEIRAI ,win ;
<br />`t 1! n XII=�+
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND H1.111 0 U4
<br />CERTIFICATE OF DEATH 411. 4
<br />LINCOLN, NEBRASKA
<br />CESS 2T' CERTIFIES
<br />LTH AND
<br />S371
<br />'
<br />1. DECEDENTS -NAME (First. Middle, Last. Suffix)
<br />Ben Lavere Schoneberg
<br />2,' t " Arta
<br />Male ' ,.
<br />:OPD` latM,ay,YI-)
<br />October 1, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />6a. AGE -Last Birthday
<br />61). UNDER 1 YEAR
<br />6e. UNDER 1 QAY
<br />:0. DATE OP BIRTH (Me., Day, Yr.)
<br />Wood River, Nebraska
<br />(Yrs.)
<br />85
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />February 23, 1925
<br />7. SOCIAL SECURITY NUMBER
<br />506-22-6206
<br />ea PLACE OF DEATH
<br />IS2SINIALi ® inpatient gIHE6: ❑ Netting Home/LTC 0 Hospice Facility
<br />6b. FACILITY -NAME (f not Institution, glee street and number)
<br />0 ER/Outpatient ❑ Decedents Homs
<br />0 DOA ❑OtlmgSpsclfy)
<br />Veterans Affairs Medical Center
<br />6a. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />ad. COUNTY OF DEATH
<br />Hall
<br />6a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />M. STREET AND NUMBER
<br />206 Wetzel St.
<br />9e. APT. NO.
<br />W. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® Yea ❑ No
<br />ro
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wire, give maiden name.
<br />Eunetta Mamie Rathman
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ben Emil Schoneberg
<br />12. MOTHER'S -NAME (Ff,L Middle, Maiden Bunion's)
<br />Vera Tuffs
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service N Yes.
<br />1/27/45 -1 1/17/46
<br />(Yes, No, or link) Yea
<br />14a. INFORMANT -NAME
<br />Eunetta Mamie Schoneberg
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16. METHOD OF DISPOSmON
<br />❑Berlel Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE N0. . .
<br />161. DATE (Mo., Day, Yr.)
<br />October 2, 2010
<br />®CmmetIon ❑E"ta"I'ma"t
<br />❑RemeM ❑Oa,eritaae 1yI
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<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 />17b. Zip Code
<br />68801
<br />1 /, I To Be Com CERTIFIER
<br />Completed by:
<br />CAUSE OF DEATH (See Instructions and examples)
<br />IN,siw, er sempllsaeons• tut din°"y mute the death. DO NOT entrtmnWal rents such as maim WOK
<br />APPROXIMATE INTERVAL
<br />1a. PMT 1. Enerar etM(aefattER -dirern,
<br />respiratory cant, et va*laaaebrWallon wanaut slmMne tea etiology. 00 NOT ABBREVIATE. Enter only one caul on a Mm. Add additional noes If twenty.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final ,y c�,4�
<br />eat or eondHion rseWtlng a) `.Q\\]`QrC1(�C\(l./^ C\I'f C•S1di
<br />\
<br />onset to death
<br />k.v.i\.\}in
<br />death)
<br />\`DUE TO, OR AS A CONSENCE OF:
<br />Sequentially list conditions, N bj ��i. `
<br />any, leading to the caw listed (� W Q C <NCCtl ',C\�Ii° �� \1) Q �t�1 �X
<br />onset to death
<br />on linea DUE TO, OR AS A CONSEQUENCE OF: �'Y
<br />�N
<br />Enter the UNDERLYING CAUSE c) . M Q &k141\C/*15 � Q 'ores:, n 0016 b (5 R e..
<br />onset to death
<br />(disease or Injury that initiated
<br />tM ewnte rewiring in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />d) COS *\11t,caa N� the \v.N
<br />onset to death
<br />16. PART 0. OTHER SIGNIFICANT CONDITIONS-;onditlons contributing to death but not derMng vane ghren M PART L
<br />t_C Q
<br />9.S\b,'ti
<br />�,F'M1Q�T�a a...sti .,cx\ d tkh I t0.,n *1Act\DC Coc9Rok-4Q, 14SyCA'LS"
<br />19. WAS MEDICAL EXAMINER
<br />OrtCORON CONTACTED?
<br />❑ YES NO
<br />20. IF FEMALE: 1
<br />❑ Not pregnant within past year
<br />*Ia.MANNER OF DEATH
<br />Natural 0 Homicide
<br />21b. IF SPORTA INJURY
<br />0 Dever/Operator
<br />21c. WAS AN AUTOPS7 PERFORMED?
<br />0 YES YI NO
<br />❑Pregnant at time et death
<br />❑ Not pregnant, but pregnant wltflln 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑Unimown If pregnant within the past year
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />❑Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22e. PLACE OF INJURY -At harm, farm, sheet, factory, office buNdlna, cambwtlan elle, etc. (Sway)
<br />22d. INJUR T RK?
<br />o YES NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET a NUMBER, APT. N0. CITYfrOWN STATE ZIP CODE
<br />-1
<br />23e. DATE OF DEATH (Mo., Day, Yr.)24..
<br />OC'4k(bC \ c e)\ Co
<br />.S i
<br />DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />I,.
<br />1.0.4
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />C�c:c.`o„C\ x111,1
<br />230. TIME OF DEATH
<br />o :�A or
<br />Y
<br />c
<br />24e. PRONOUNCED DEAD (Mo„ Day, Yr.)
<br />24d TIME PRONOUNCED DEAD
<br />m
<br />..
<br />23d. To the best of nye; knowledge, death occumd at the time, date and place W 2
<br />sed dw to the caw.(a) stated. (Signature and Title) $ C
<br />OWI- i - . nEft_dat, . #10 10 .
<br />. / 0 O V
<br />u ii
<br />24x. On the deal. of .xamilratlon andror tsstipatlor4 l. my opinion death oean.d
<br />at ttm time, date and plat. and dw to tits cause(.) stated. (Slanab•• and Title)
<br />26. DID O USE CONTRIBUTE TO4yEDTH? 26a. HAS ORGAN OR TI DONATION BEEN CONSIDERED?
<br />❑ YES ❑ NO 0 PROBABLY NKNOWN 0 YES NO
<br />(
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ' 0 YES NO
<br />`27. NAME, TITLE�-AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo or Print)
<br />,
<br />e',c`'1n vt AFTL \NC . D Y A V'C\ kcal)/ 0.0 AQ C raieN1 N u�t(\l ,•Loci-AZ.1\otc1N an'
<br />Y REGBTRAR Mo Dy Yt 1
<br />P
<br />26a REGISTRAR'S SIGNATURE
<br />. DATE FILED B ( , •
<br />OCT 12 2010
<br />
|