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<br />fli HEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA 1 RUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />,STATE OF NEBRASKA
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<br />OATS SAF ISSUANCE
<br />3/23/2023
<br />LINCOLN, NEBRASKA
<br />202302296
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<br />SARAH BOHN>NKAMP` ;
<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 />4 DECEI*NVS+NAME (First, Middle, Last, Suffix)
<br />Francis Dani Schaaf
<br />k CITYAND'STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />T S0CtA(,
<br />505-38
<br />IMUR17Y NUMBER
<br />1#36
<br />8a. AGE - Last Birthday
<br />(Yrs.)
<br />88
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />224 I-akeSide Drive
<br />Sc. CITY OR TOWN
<br />Gland Island
<br />OF DEATH (Include Zip Code)
<br />saam
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. S'r0ETANO NUMBER:::
<br />224 Lakeside Drive:
<br />9b. COUNTY
<br />Hall
<br />18a. PAARITALatATUSAT;TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FA/NEWS-NAME (Fust, Middle, Last, Suffix)
<br />Elmer Julius Schaaf
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or UM.) Yes 10/12/1953-10/11/161
<br />18 METHOD OF DISPOSIT1ON
<br />b41Burlai ❑ Donaiion
<br />❑;Cremation;:❑ Entombment
<br />❑Removal' ' ❑ Other :Specify)
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER'I DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOS L ❑ Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 03502_
<br />3. DATE O11 -DEATH (oda, Day Yr ):.
<br />March 10, 2O2
<br />6.
<br />DATE CF BRTN'(Mo., Day; YK)
<br />Novembe�91934 .
<br />OTHER 0 Nursing Home/LTC
<br />D Decedent's Home
<br />❑ Other (Specify)
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />Of. ZIP CODE
<br />68801
<br />19b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give mai
<br />Constance Elizabeth Sherrill
<br />12. MOTHERS -NAME (First, Middle, Maiden Surname)
<br />Ella Maeii,. Moore
<br />14a. INFORMANT -NAME
<br />Constance Elizabeth Schaaf
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />Bd CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />18b. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Grand Island
<br />1Ta. FUNERAL NOBE NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths F`unerai Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEAThi (See instructions and examples)
<br />14b. RELATI
<br />Spouse
<br />NSHIP TO DECEDENT
<br />18e. DATE (Mo. Oay ;Yr)
<br />Match 17.2
<br />13. PART I. Enter the chain of events- diswees,: injuries, or complicatlons.that directly caused the death. DO NOT enter terminal events such as cardiac &mist,
<br />respiratory arrest or ventrifularfibrillation without showing the etiology. DO NOT ABBReVIATE. Enter only one cause on mane. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cardiac arrest
<br />IMMEDIATE CAUSErnai
<br />disease orconeri er reartiblg
<br />In Owns DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially" list conditions, it b) Ischemic cardiomyopathy
<br />any, leading to the eaves
<br />1?Lt ZipGode
<br />,88801'-
<br />onset t4:$
<br />Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />home obtct' s res ►ve pulmonary disease
<br />:::`
<br />Esti/eliteONDERLYINGCiit%81? C)Ch
<br />Idleeam sr injOrilhas waded
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />c
<br />18 PART ILOTHER SI
<br />20. IF FEMALE:: : ,:,
<br />A of pregnant within wt'
<br />0:
<br />❑ pregnant Shim& of deatp
<br />❑ 1ddt piegnant; but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant. 43 days to 1 year before death
<br />Unit.. apfepnenavdthkithepastyear.
<br />GNNOANT CONDITIONS-Conditlona contributing to the daeth but not resulting Ina*underlying cause given in PART I.
<br />22a. GATE OF $JURY (Mo„ Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES' ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural. ❑ Homhida
<br />❑ Accident 0'44e, Pending InvaaGgatIon
<br />0 8ulc de ❑ Could not be debmdned
<br />22b.' TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Ddvu/Operator
<br />E Paswnger
<br />❑.PedesMlan
<br />o Other (Specify)
<br />19. WAS MEDICO EXAMEN/IR
<br />OR CORONER CONTACTED"
<br />❑ YES ® NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑, YES _ No
<br />21d. WERE AUTOPSY FININGS AW1/411.AMA
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ' ❑ NO .... .....
<br />22c. PLACE OF INJURY -At home, faun, street, factory,' office building, construction site, st0,:I
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221, LOCATION OF INJURY;;: STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 10,°2023
<br />cITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Mar9h i& 2023
<br />3d. Ta time Irsat of my knowledge, death occurred at the time, date and place
<br />and: due to the ceuse(s) stated, (Signature and Title)
<br />Todd A Woollen, MD
<br />23c. TIME OF DEATH
<br />09:10 PM
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TII
<br />DEATH
<br />ZAP CODE
<br />24d. TIME PRONOUNCED DEAD
<br />Cos. CNt the best of examination and/or Investigation, In my opiniaiiesBh a ttived at
<br />the time, date and place and due to the csuaa(e)stated (Srjlmrture and T ie)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES NO J PROBABLY 0- UNKNOWN
<br />2T. NAME, TITLDADDRESS OF CERTIFIER (Type or Print
<br />Todd A Woollen, MD, 2201 N Broadwell Ave, Grand Island, Nebraska, 68803
<br />28b. WAS CONSENT GRANTED? ,
<br />No, Applicable If 26a is NO YES
<br />NO
<br />28a. REGISTRAR'S SIGNATURE
<br />8
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, fir.)
<br />March 20, 2023
<br />
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