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<br />/4, �qd,.,� STATE OF NEBRASKA
<br />tSi1 W4..:, y !la two. '4S%'(tyll'/1;ifftu T ass wialt, r r4414magit�pe. 1 ,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE' AE
<br />TRUE COPYOF 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 />DA TE oPISSw Nc'E
<br />5/26%2023
<br />LINCOLN, NEBRAS
<br />202302799
<br />jolt
<br />SARAH BOHNENKA1 11 '7
<br />ASSISTANTSTATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />DECEDENTS -NAME #First, Middle, Last, Suffix)
<br />Shirley_ Jean Schieno
<br />CERTIFICATE OF DEATH
<br />1.
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />e
<br />Bridgeport,: Nebraska
<br />800IAL SECURITY NUMBER
<br />50 52.4632
<br />Sb. FACILITY -NAME (if rtoi Inti
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />80
<br />stitution, give
<br />The Heritage at Sagewood
<br />street and number)
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSE ITAL 0 Inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />$c. CITY OK TOWN OF DEATH (Include Zip Code)
<br />Grand(Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />ed. STREET AND NUMBER
<br />1920 Sageaood Avenue
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />Widowed : 0 Divorced 0 Unknown
<br />0 Married, but Impend,,
<br />FATHERS NAME (FIrSt MI
<br />Carl AlrthurMartin I;HofFE
<br />Suffix)
<br />13. EVERIN U.S.ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />®.Burial 0 Donation
<br />0 Cremation ;;❑ Entombment
<br />❑Removal 0 Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (MO., p
<br />May 22, 2023
<br />6. DATE OF BIRTI' o., Dari Yi'il
<br />October 2141942
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (Specify)ASSISTED LIVING
<br />9d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />ea, Melte CITY LIMITS
<br />YEs p N0
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nit
<br />John - Schieno
<br />12 MOTHERS4 ME (First, Middle,
<br />F. Pauline Pearl Reimers
<br />14a. INFORMANT -NAME
<br />Sadie Knapp
<br />lea. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />lie. FUNERAL HOME:NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Agfei funeral Home 1123 W. 2nd, Grand Island, Nebraska
<br />16b. UCENSE NO.
<br />1537
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF'DEATH(See instructions and examples)
<br />ia. PART I. Enter the chain of.evrknts- .diseases, injuries, or complIcations-that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibHNatiort without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines 8 necessary.
<br />IMMEDIATE CAUSE:
<br />BeMEOIATS CAUSE (Proal a) vascular dementia
<br />diseaseorcommon res ing:;<;. -..... .
<br />in deatit2::,: ...
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially list conditions, if b)
<br />any. *woo to dot ceu55
<br />Enter the UNDERLyiNG CAUSE<
<br />(disease tit injury that initiated
<br />tAeevents resulting hi death)
<br />18. PART fi.0'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />SIGNIFICANT
<br />14b. RELATIONSH
<br />Daughter
<br />TODECEIN'
<br />16c. DATE (Ma, Day.;Yr.)
<br />May 30, 2023
<br />Nebraska
<br />17b 'ii Go
<br />688x4
<br />NDITIONS.Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />20. IF FEMALE:;:.:.
<br />Q Not prugn snl iyiMM pest year
<br />Pregnantat this of death
<br />❑ Hot prageantr Out pregnant�within 42 days of death
<br />0 Not pregnant, but pregnant 43 7:48t:0
<br />ays to 1 year before death
<br />Ueknewn If pregn5M wltih6. past year
<br />22a. t7ATE OF tN.uURY (Mo ;:Day, Yr.)
<br />22d. INJURY AT WOR
<br />YES ❑ N
<br />21a. MANNER OF. DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />o Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION
<br />Driverioperator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />INJURY
<br />onset to death
<br />19. WAS MEDT AL EXAMINER...
<br />OR CORONER 0ONT$1Sb I
<br />❑YES` ®NO
<br />21c. WAS AN AUTOPSY PERFORMEDT
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AWei1Bfi$
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑: NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site,
<br />DESCRIBE HOW INJURY OCCURRED
<br />CATION OF INJURY.STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 22, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />likktTothte best of my knowledge, death occurred at the time, date and pace
<br />end des to the causeThis)
<br />s) stated. (Signature and
<br />Travis S Hageman, MD
<br />May 23 2023
<br />stir ($ppciI
<br />CITY/TOWN
<br />29c. TIME OF DEATH
<br />04:40 AM
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP ;we
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD....
<br />240. On the basis of examination and/or investigation, In my opinion death occWfed.at
<br />the time, date and place and due to the causes) stated. (Signature and 'ate)
<br />2$. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Y $ ❑ NO ❑ PROBABLY 0 UNKNOWN
<br />2i. NAM TITLE :AND AREBS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68603 •
<br />28a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES
<br />Sri 8.,in.
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 285 is N0, . ` .❑ YF»S
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 23, 2023
<br />
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