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STATE OF NEBRASKA • WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALAVi b THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA rM HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR,,RIT41. REC1 A, DATE OF ISSUANCE 01/20/2011 202400035. �l 'IT CERTIFIES MEW Q .TW AND rzt LINCOLN, NEBRASKA GS Cj'_tS STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SER CERTIFICATE OF DEATH t LL • , 1100131 To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Brenda J Schmidt 2. SEX , , Female , - ;ATE b BEAM (Mo., Day. Yr.) 'alti pry 12, 2011 h 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Keamey, Nebraska (Yrs.) 50 MOS. DAYS HOURS MINIO , ' November 28, 1960 7. SOCIAL SECURITY NUMBER 508-90-5909 8a. PLACE OF HOSPITAL DEATH ® inpatient OTHER 0 Nursing Home&LTC 0 Hospice Facility Sb. FACILITY -NAME (If not Institution, give street and number) Mary Lanning Memorial Hospital 0 ER/Outpatient 0 Decedent's Homs 0 ooA 0 Other (Specify) Sc. CITY OR TOWN OF DEATH (include Zip Coble) Hastings 68901 I gd. COUNTY OF DEATH Adams 9a. RESIDENCE -STATE Nebraska Sb. COUNTY Adams Sc. CITY OR TOWN Doniphan 9d. STREET AND NUMBER 930 West Rainforth Road Se. APT. NO. 9f. ZIP CODE 68832 8g. INSIDE CITY LIMITS • YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, glue maiden name Michael V Schmidt 11. FATHER'S -NAME (First, Middle, Last, Suffix) Carl F Barton 12. MOTHER'S•NAME (First, Middle, Malden Surname) Betty L Sands 13. EVER IN U.S. ARMED FORCES? Give dates of service H Yes. (Yes, No, or Unk.) No 14a. INFORMANT•NAME Michael V Schmidt 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE James M. McLaughlin 16b. LICENSE NO. 951 16c. DATE (Mo., Day, Yr.) January 17, 2011 ❑ Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Parkview Cemetery Hastings Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Livingston-Butler-Volland Funeral Home, 1225 N. Elm, Hastings, Nebraska 17b. Zip Code 68901 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER i IS. PART I. Enter the ghain of events - diseases, Injuries, or complications4hat directly caused the death. DO NOT enter termini events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause en a ane. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Metastatic Small Cell Lung Cancer disease or condition resulting onset to death 18 Months In death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, If b) any, leading to the cause listed oneettb deeds on lite a DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset t0 death the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: LAST 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 21 NO 20. IF FEMALE: ® Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH ® Natural 0 Homicide Accident Pending Investigation 21b. IF TRANSPORTATION INJURY 0 DriverlOpntor ❑ P8ienger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ® NO ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 0 ❑ Suicide Could not be determined 0 ❑ 0 Pedestrian 0 Other (Specify)TO 21d. WERE AUTOPSY FINDINGS AVAILABLE COMPLETE CAUSE OF DEATH? Ni YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction sue, etlt. MINIUM 22d. INJURY AT WORK? ❑YES ❑NO 22e. DESCRIBE HOW INJURY OCCURRED ,22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE .S 1 23a. DATE OF DEATH (Mo., Day, Yr.) January 12, 2011 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEA'CH E ).23b. DATE SIGNED (Mo., Day, Yr.) 13, 2011 23c. TIME OF DEATH 02:22 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD -January . To the best of m y knowledge, death occurred at the time, dale and place Etin and due to the caheelq stated. (Signature and Tito) Michael G. Skoch, MD s is 24e. On the basis of examination antyer Irhvestlpalbn, In my spinier death eecwws at time, date air pMw and d,e to the cause(s) Mated. (signature and Title) ... 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ®YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE 0 YES DONATION BEEN CONSIDERED?I ®NO 26b. WAS CONSENT GRANTED? t.Not Applicable If 26a Is NO 0 YES 0 NO NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, Michael G. Skoch, MD, 223 E 14th St. #100, Hastings, SICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) Nebraska, 68901 (Type or Print) . REGISTRAR'S SIGNATURE, / ,6 A° 26b. DATE FILED BY REGISTRAR (Mw., Day, Yr.) January 18, 2011 2 0-FZ