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<br />STATE OF NEBRASKA
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<br />1+1 1EN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA 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
<br />ATE OP ISSUANCE
<br />........ ........ ...............
<br />5/26/2023
<br />LINCOLN, NEBRASKA
<br />202400.524:
<br />202302800
<br />SARAH BOHNENKAMP T
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />!. DECEDENTS NAME (Fi'at, Middle, Last, Suffix)
<br />Sh1i1 .lean Sch(eno
<br />CERTIFICATE OF DEATH
<br />4. CFTY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />BridoepOrt,::Nebraska
<br />7 sOCJAL SECuRITY ;quoins
<br />505-524632
<br />Ba -AGE - Last Blrthday<
<br />(Yrs.)
<br />80
<br />8bi FACILITY -NAME (If not Institution, give street and number)
<br />The Heritage at Sagewood
<br />8c CflY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d S1BEET AN (3 NUM BER:
<br />1920 Sagewood Avenue
<br />9b. COUNTY
<br />Hall
<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 />HOSPITAL b patient
<br />❑ EROu patient
<br />❑DOA
<br />10a. AVOWAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />Ba 0 Married, bot separated Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First,,.: MIadle,
<br />Gar' Arthur Martin :.;Hoffer
<br />13. EVER(N U 8 ARMEDr
<br />(Yes, No, or Unk.) No
<br />RCE
<br />Last, Suffix}
<br />Give dates of service if Yes.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mos, Day Yr.)
<br />May 22, 2023
<br />8. DATE OF BIRTH (Mo., Day, YRI
<br />October 21,.1942::
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (SpecIfy)AS431STED LIVING
<br />(
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />00,
<br />10k, NAME OF. SPOUSE (Mat, Middle, Last, Suffix) If wife, give maiden nems
<br />John Schieno
<br />14a. 1NINFORMANT-NAME::'
<br />Sadie Knapp
<br />12. MOTHER'&NAME (First, Middle, Maiden Su
<br />Pauline Pearl Reimers
<br />DE cm' Liebe :
<br />rEB; ❑ NO.
<br />ame)
<br />14b. Nei -M ONSHP O DEOSIfiENI
<br />Daughter
<br />f5. METHOD OF DISPOSITION
<br />jsuriat ❑ Donatian
<br />❑:Grentatioic.;Q Entombment
<br />❑ Ramovsl ❑Other {Specify)
<br />18a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />18b. LICENSE NO.
<br />1 537
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION =` CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />1Ta. FUNERAL OME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home,' 1123 W. 2nd, Grand Island, Nebraska
<br />woe,
<br />18c. DATE (M
<br />May 30, 202
<br />CAUSE OF DEATH (See instructions and examples)
<br />it. PART L Eller the chain of events- diseases, Injuries, or complications -that directly caused the death. DO NOT enter temunai events such as cardiac tumid,
<br />respiratory arrest, or ventricular fibneation without showing the etiology. 00 NOT ABBREVIATE. Enter only OM cause one line. Add additional lines if naeessary.
<br />IMMEDIATE CAUSE:
<br />ea1ATECAus (Pksat a) vascular dementia
<br />rxealtre or grgidatW. reeathtt,,
<br />in death;
<br />DUE TO, OR A CONSEQUENCE OF:
<br />Sequentially list Conditions, it b)
<br />any, leading to the cause listed
<br />Entar`tIw: UNDEtIYi�
<br />fdlaelse or irVury-#ii ii
<br />are events
<br />LAST`'
<br />resulting In. de
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />PART li. OTHER SIGN(F(CANT CONDITIONS -Conditions contributing to the death b
<br />L
<br />2Q. IF FEMALE:
<br />.N54.114i01110 waNtl prat year
<br />#Ntgnem.asiste ottfeath
<br />❑ Nrot pregnard, but pnlgnan t within 42 days of death
<br />0 Not pregnant, but pregnaM43 days to 1 year before death
<br />Unknown tpr gn*nt within the pitta year '
<br />22d. 1
<br />TE OF INJURY f Mq. Day, Yr.)
<br />Y AT WORK?
<br />NO
<br />21a. MANNER OF. DEATH
<br />3 NatureI ❑ (ant ..0
<br />❑ meldem ❑ Pandttiq in -71!S: ❑
<br />Suicide Coutd not be determined
<br />Nebraska
<br />lie, Ztp
<br />68801
<br />notresulting to the of derlying cause given in PART I.
<br />22b. TIME OF INJURY
<br />22c PLACE1F IN
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />226 t OCA1 iDN OF INJURY 1STREET & NUMBER, APT NO.
<br />2
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 22, 2023
<br />23b. DATE SIGNED 1740,, Day, Yr.)
<br />Mau
<br />23V2023
<br />cITY/TOWWN'':''
<br />23c. TIME OF DEATH
<br />04:40 AM
<br />23d Ta tits bast of r4P knowledge, death occurred et the time, date and place
<br />alt. due to the chusels) stated. (Signature and TSN)
<br />Travis S. Hageman, MD
<br />21b.IF TRANSPORTATION INJURY
<br />Dnvar/Opsretor
<br />Puaadbet
<br />L.SPedestnan
<br />❑ Other (Specify)
<br />19. WAS MClib;EXNER: ;:
<br />OR CORONEr4:CONTACTED?
<br />❑ YEs 111 NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑vas laN
<br />21d. WERE AUTOPSY FINDINGS AVAILA8t,;E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑
<br />Yu 0: NG .
<br />URYAt home, farm, street, factory, office building, construction'
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.).
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH',
<br />24d. TIME PRONG
<br />t1R. Ort the bible of examination and/or Investigation, M my opinion death Occurred a1
<br /><thnk .date and place and dos to the cause(s) stated. (Signature *MOO) .,
<br />28x. HAS ORGAN OR TISSUE DONOON SEEN CONSIDERED?
<br />❑ YES {;NO
<br />DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />tiff YES ❑ NO Q PROBABLY ❑ UNKNOWN
<br />NAME, TiTLEAN©.AD.DREIS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand (stand, Nebraska, 68803'`
<br />28a. REGISTRAR'S SIGNATURE'
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a Is NO ❑ YE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.).
<br />May 23, 2023
<br />
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