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STATE OF NEBRASKA
<br /><a ISTIT►t W:: ✓r ...ArG41111TOOD.
<br />WHEN ; THIS "COPY CARRIES THE RAISED SEAQ IlE STATE OF NEBRA.
<br />CERTIFIES THE DOCUMENT BELOW TO BE' l TRUE' COPT* OF THE ORIGINAL REI,
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,: VT
<br />RECORDSGF'F%CE, WHICH IS THE LEGAL DEPOSITARY FOR ITAL>1 EORDS
<br />DATE OFISSUANue
<br />12/17/2019
<br />LINCOLN, NEBRASKA
<br />RUSSELL FOSLER' ,
<br />'..„2024.02636 A DEPARTMENT OF UEALIN
<br />ANI) 141141AN SERVICES
<br />-STATE _OF NEBRASKA - DEPARTMENT OF HEALTH.AND :HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Mlddfe,
<br />Robert Charles Schleicher
<br />L
<br />Suffix)
<br />Valdosta, Geon
<br />7. SOCIAL SECURITY
<br />-60.-9250....
<br />R
<br />ggCiLt9 3:y�tME of, oecinStitutlon; gtYO
<br />CHP :HeskhAerg.
<br />aMercyr
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68124
<br />ea.HES{DENCE &T
<br />t+Nobraska ..:.
<br />nur
<br />Sb. COUNTY
<br />Hall
<br />6a. AGE; -taxi t3iHEhday:
<br />fY)
<br />61
<br />5b UNDER -1 YEAR
<br />2. SEX.
<br />Male
<br />UNDER 1 DAY
<br />lfliGlR ,
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE
<br />:D
<br />t t erFiber i�.
<br />e. la DF 0Th(
<br />GFand :Island`
<br />6d. COUNTY OF DEATH
<br />Douglas
<br />Sd. STREE`rAND'NUMBE
<br />4043 Lamb Chop Lane
<br />14MARITAL ST TU$ A ...E OF DEATH ® Married QQ Never. Married
<br />Married, but4eparated ©;Widowed - Q Divorced .0' Unknown
<br />1. FAT#iER'SmANIE (First; 'Midge,
<br />Charles W Schleicher
<br />:E\F.ER Ifi U:S:ARMED FORCES?
<br />(YPsNo,orUttt}Np. .
<br />16 METHOD OP DJSPOSPOON
<br />BOB: Q Dotsatcat
<br />Cremetlon Q Entombment
<br />Q F etlttr hal Q Other(Specify)
<br />ravel
<br />sofs
<br />Suffi )
<br />If Yes.
<br />9e. APT. NO.
<br />101:. NAME QF SPOUSE (First..: Middle,
<br />Arlene . Naughtin
<br />12. MOTHERS NAME (First,
<br />Ann P Cahela
<br />.ZIP CODE,
<br />80
<br />14a. INFORMANT NAME :..:
<br />Arlene .St i)eicher ;!
<br />lea, EMBALMER SIGNATURE
<br />Jason S. Billings
<br />16d. CEMETERY, CREMATORY OR OTHER Lt3CATION
<br />Grand Island City Cemetery
<br />vs: F UNERAL C(G EE i1AME AN.D MA UNG ADDRESS (Street, City or Town, StS4
<br />Curran Funeral Chapel, 3005 S. Locust St;, Grand Island Nebraska
<br />fib. LICENSE NO.
<br />1291
<br />CITY 1 TOWN
<br />Grand Island
<br />20
<br />STA
<br />CAUSE OF DEATH (S jnstructigns and examales)
<br />sin of events--daentilk hairier, or complicadonathet directly causal the death tro ho'T entertenninat ever is such as eatdac salt
<br />Ar ventriculart brfthsdon without shdueng the etiology. DO NOT A8EPTITS C E Enteronkellea us a pita, line. idd additional linos it n u.Mary.
<br />IMMEDIATE CAUSE:
<br />—r vrsh ui�v r,; Inv:
<br />yedEtatryr lids....
<br />feeeteeiteiih«�srase'jiaied
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />) Intraoperative Bleeding
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CRUSE C) Aortic Abscess
<br />eseeese er ielere test eetieve .:::;
<br />the wiser: rentatna: iii oast)
<br />t
<br />.PUE TO, OR AS A C
<br />d)
<br />4& PART IL OTHEt SIGNIFICANTGON1$TJON
<br />SEQUENCE OF:
<br />IF:fEMA
<br />�: Not Oren. peat' year
<br />. Q
<br />Ping/ant at time of death
<br />P[eW!a!n, but l 9flhnt. Fithin 4E days of Math
<br />ptegnam digs to Tyarhefore death
<br />ng to
<br />21a. MANNER OF DEATH
<br />3 Natural Q Hatfield*
<br />Q ACddent 0 Pending ins..
<br />Q sukid. - ❑ Cmdanatb°
<br />resulting In the underlying Eau
<br />kit
<br />OF
<br />IN;IURY IAT. WORK`
<br />YES>"' :;::.. ...
<br />ATION OF INJU
<br />�NaEEN.:ilis p#at year
<br />Y (Mo., Day, Yr.)
<br />1b:IFTRANSPORTA,
<br />Q Drtver/Operator
<br />Passenger
<br />QPadeatrisn
<br />apt4.0i1Pkte
<br />22b. FFME, OF INJU
<br />1r
<br />22c. PLACE OF INJURY At h
<br />street, f
<br />in PART I.
<br />4U'MOi?S:1F:PER: R
<br />btd
<br />RISE HOW I
<br />STREETS NUMBER, APT.
<br />[ 10.0a:Pat)04114 (Mo,, DOB Tr.)
<br />41StdveMber:161, 201:9
<br />DA €S:SIGNED (Mo., Day, It.
<br />b DATt? SIGN.(Mo., Dey, Yr.) . 23c. TIME OF DEATH
<br />December 9, 2018 . 09:3§ PM
<br />3d. To !behest of my knovtladSe, death of curved at thetaw, date and place
<br />and due to the ceusele) stead: (Signature and Tele)
<br />Rabic. Emsaierrt,IAD
<br />DID;, ;U$ELOlimes TE TO THE DEATH?
<br />Q YES NO Q PROBABLY 0 UNKNOWN
<br />NAME, TITLE AND ADDRESS OF CERTIFIER (Type or,
<br />gable Er>1saiern ,M.D , 7500 Mercy Rd-, Omaha, Nebraska 68.124
<br />...IMO it
<br />HAS'ORGAN:F)R TISSUE':W:01
<br />[] YES MI NO
<br />taamtnatien.'end/or investl5
<br />nd pace and due is ins esti
<br />BEENsCONSlDERED?
<br />
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