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<br />WHEN THIS 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
<br />DATE OF ISSUANCE
<br />12/11/2020
<br />LINCOLN, NEBRASKA
<br />1
<br />20210675;
<br />r b?Jo.,101 1344
<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 />1. DECEDENTS NAME (First, Middle, Last, Suffix)
<br />Jeffrey David Schutz
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lexington, Nebraska
<br />. 7. SOCIAL SECURITY NUMBER
<br />v 507-78-9537
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<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />51
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />0 ER/Outpatient
<br />0 DOA
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS. I DAYS
<br />HOURS
<br />MINS.
<br />2017362
<br />3. DATE OF DEATH (Mc., Day, Yr.)
<br />December 1, 2020
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 8, 1969
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />Grand island 68803 Hall
<br />9a. RESIDENCESTATE
<br />Nebraska
<br />d. STREET AND NUMBER
<br />2404 South August St.
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />()Hospice Fac*fty
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />fig, INSIDE CITY 1(MITs;
<br />® YE$ ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Michelle L Jongma
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Merlyn Dean Schutz
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Janice Kay Bailey
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yea, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Michelle L Schutz
<br />14b. RELATIONSHIP TO DECEDENT''
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Etude! ❑Donation
<br />511 Cremation: 0 Entombment
<br />Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />16b. LICENSE NO.
<br />1448
<br />16c. DATE (Mo., Day, Yr.)
<br />December 6, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />CIN / TOWN
<br />Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAL. HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />EEwood Funeral Home, 302 Smith Avenue, PO Box 95, Elwood, Nebraska
<br />17b. Zip Code
<br />68937
<br />CAUSE OF DEATH (See instructions and examples)
<br />10. PART I. Ender the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Brain Hemorrhage
<br />IMMEDIATE CAUSE (Final
<br />diabase or conditiah restthing;
<br />In death)
<br />Sequentially list conditions, If
<br />any, leading to tip cause listed
<br />on line a.
<br />EMer the UNDERLYING CAUSE
<br />(disease Or injurythat Initiated
<br />the events rebuking in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Metastatic Brain Tumor
<br />APPROXIMATE INTERVAL
<br />onset: Nt death.
<br />6 Hours
<br />onset to death
<br />3 Days
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Metastatic Brain Cancer
<br />onset to death
<br />6 Weeks
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART I). OTHER SIGNEFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART 1.
<br />19. WAS MEMCAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF. FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at dine of death
<br />❑
<br />Not pregnant,but pregnant within 42 days of death
<br />0 Not pregnant, but 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 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES RINO
<br />21d. WERE AUTOPSY F*NDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />22a. <DAM OF INJURY (Moi: Day, Yr.)
<br />0>
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<br />a.
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,
<br />:. (Speciyj
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22E LOCATION OF INJURY STREETS NUMBER, APT.NO. CITY/TOWN
<br />STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 1, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />December 7, 2020 01:49 PM
<br />23d. To the best of my. knowledge, death occurred at the time, date and pace
<br />and due to the cause(s) stated. (signature and Tek)
<br />Daniela A Abrams, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death oCCUrred et
<br />the time, date and place and due to the cause(s) stated. (Signature and Tale) I;
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES igj NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES f1 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 28a is NO ❑ YES
<br />El NO
<br />27. NAME, T1TLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Daniela A Abrams, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE����
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />December 8, 2020
<br />
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