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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTME
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOS1
<br />DATE OF ISSUANCE
<br />04/23/2015
<br />LINCOLN, NEBRASKA
<br />2024011 46
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND Hf 11y i
<br />CFRTfFICATF OF DFATH ':'s
<br />To be completed/verified by: FUNERAL DIRECTOR 1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix) t'
<br />Joyce Ann Schultz
<br />i " '►!.tir010
<br />°
<br />�)p. )
<br />1 $ t
<br />55
<br />AATE
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5r,°
<br />AGE •Last Birthday
<br />5b. UNDER 1 YEAR
<br />c
<br />ie,PND TtAAYt .
<br />OF it
<br />d DATE IF 81R{#fet r aiy, Yr 1
<br />St. Paul, Nebraska
<br />(Yrs.)
<br />_ 81
<br />MOS.
<br />DAYS
<br />I4OURS
<br />MINS.
<br />c -
<br />March 15v`1f '
<br />7. SOCIAL SECURITY NUMBER
<br />506-40-1598
<br />Oa. PLACE OF DEATH °
<br />0 Inpatient a 21 Nursing KomeILTC , .: 0 t bilplcs ROMP" '
<br />eb. FAG1LITY-NAME (If net Institution, give streetaltd number)
<br />Wedgewood Cara Center
<br />0 ER/Outpattent 0 Decedent's Hcilitt g g ;.
<br />0^OOA 0 txbar (St,scit , , f • , , ..., u _ ,
<br />So. CITY OR TOWN OF DEATH (IpelUde 7!p Gode),. ,DEA
<br />Grand Island 68803 ' .
<br />T N
<br />H ll (:) b l ;
<br />Ss. RESIDENCE -STATE
<br />Nebraska
<br />Ob. COUNTY
<br />Hall
<br />9c. CITY OR TOWN a i
<br />Wood River I' y
<br />d. STREET AND NUMBER
<br />8492 West Schultz
<br />0e. Alit NO.
<br />Of. ZNP CODE
<br />epes3.
<br />-
<br />pi 1 111, 1J2f11 s .,,
<br />t pp
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed ]'Divorced 0 Unknown
<br />lY
<br />lob. NAME OF SPOUSE (First, MIddIe, Last Rix) If mew give maiden Rams * I
<br />Wilbert E Schultz
<br />11. FATHERS -NAME (First Middle, Lest, Suffix)
<br />Charles Muller
<br />12. MOTHER'S -NAME (First, M icy Maiden Surn i:KO
<br />Frieda R Dobish
<br />13. EVER IN U.S. ARMED FORCES? Give dates of eervice if Yea.
<br />(Yes, No, or Unit) No
<br />14a. INFORMANT4.IAME
<br />Wilbert E Schultz
<br />156. ��CSCERT: ¢ `.
<br />S flse;,
<br />15. METHOD OF DISPOSITION
<br />[] Burial ❑Donation
<br />15s. EMBALMER -SIGNATURE
<br />Not EmbalmedAprlle11
<br />10b. LICENSE NO. 4 :
<br />10a DATE1(MQ.3iJl'.Yrl
<br />2Q1 . i f .
<br />®Cremation ❑Entombment
<br />0 Removal 0 Other (Specify)
<br />RE57141
<br />111d. CEMETERY, CREMATORY OR OTHER LOCATION CITY t TOWN
<br />Central Nebraska Cremation Services Gibbon . SE^ i
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS /Street, City or Town, State) f
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />A.
<br />" 1
<br />6
<br />CAUSE OF DEATH (Sete Instru + ons an. examq
<br />..�. 1
<br />To be completed by: CERTIFIER
<br />2. PART I. Eater the Milo Of events- -diseases, Injuries, or compaoea.nsdhat directly caused the diets. D'0 NOT enter wasn't events Much se cablac fires,; i APS 44
<br />mplratery amt or ventricular fibrillation wdhdut showing the 'doleey. DO NOT AODREVIATE. Enter only enema* en a line. Add .d4iI10naI 1111.. If netesaary. t ' , - ,
<br />deitti
<br />IMMEDIATE CAUSE: 1% ens et 4 •
<br />IMMEDIATE CAUSE (Final a) Cardidvasculer Disease t
<br />Comm or conditionsesuft6ryIn
<br />deeth)
<br />DUE TO, OR AS A CONSEQUENCE OF: t i2OHA
<br />Sequentially stet conditions, ti b) Parkinson Disease -. Ytt l
<br />any, leading to the cause listed .,
<br />„� is
<br />on ores a DUE TO, OR AS A CONSEQCENCE OF: en�dtea de j�e a
<br />Enter the endgames CAUSE C) Cardiomyopathy " i
<br />OWN= or injury that Initiated
<br />4
<br />the events retuhh,g In death) DUE TO, OR AS A CONSEQUENCE OF: 1 a i t tO
<br />LAST d) , I _ "
<br />Ssn In PART i.
<br />1a. PART IL OTHER SIGNIFICANT GbNOTIONS-COndltiona cotltHbuting to the death but not reeulNn In Ms wxlaeryinpcauas hiOR
<br />1e ISI R
<br />•,• N!R AdrEDp
<br />O YE$` ( ; NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant et time of death
<br />21s. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />Pending Imeellpdon
<br />21tt. IF TRANSPORTA'TION.INI
<br />0 Driver/Opentar
<br />In Piseng`r ..
<br />c. WAS Aft Pill l p tPOIIA ;'
<br />o .Yip ,�
<br />0 Not pregnant, but pregnant 42 days of death
<br />0 Not pregnant, but pnanant 43 days to 1 r before Beeth
<br />0 Unknown If pregnant whhin the past year
<br />0 Accident 0
<br />0 Suicide 0 Cottle not be deterrn cad
<br />0 Pedestrian
<br />. U Otter (Spdfy) ^
<br />�t���
<br />21d, WEREAUT0101 III MNG'E" ' . =
<br />71D:CC tPLETED. 4WD!
<br />, ,.
<br />0 "OS 0 'N9 e _.,•.
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 122b. TIME OF INJURY I
<br />22c. PLACE OF INJURY -At home, farm, street fastssy, Qfdas i:aa com rLctf)t ORO.4MF. (eat ,
<br />22d. INJURY AT WORK?
<br />0 YES 0 No
<br />22e. DESCRIBE SOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET A iJUMIER, APT.NO. CITYROWN STATE
<br />ys
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 16, 2015
<br />Si
<br />24a. DATE SIGNED (M0., DSy, Yr.)
<br />r` .
<br />dab. 11ME OF WASH
<br />.:. N
<br />23b. DATE SIGNED (MO., Day, Yr.)
<br />April 96,,2095
<br />23c. TIME OF DEATH
<br />07;23 AM
<br />i 1 ,
<br />t44e. PRONOUNOID{Md, Day, Yr
<br />24d.'TIM:Ao
<br />(
<br />$ F. To the beet of my knowledge, death occurred at the bate, date and place
<br />B and due to Me Caesars) sated. (Signature and Title) ;
<br />12 Kenneth Vettel, MD
<br />%
<br />3
<br />2
<br />I :;
<br />24e. Ona basis df ssaninadon aadtor Iavigeigadoh, ht my ft at { 9
<br />the d� and hies � i t t
<br />r uP «a ca».w.Med.wali�u9i
<br />�s
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 20a. HAS ORGAN OR TISSU = .ONATION SEEN CONSIDERE07
<br />0 YES ®NO PROBABLY � UNKNOWN 0 YES ® NO
<br />2Sb. WAS CONBEN'!" RAH
<br />Not Applicable if 264,1; NO
<br />1�
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIEI1(Typie or Print
<br />Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand island, Nebraska, 68803
<br />3de. REGISTRAR'S SIGNATURE
<br />2111). DATE F 1 REApr
<br />X121, 201 '!�"'t :....
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