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<br />I+YI tEl11 THIS"COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA,;IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE:;COPY:O TIE ORIGINAL RECORD ON FILE WITH THE NEBRASKA.:.DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VIAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />STATE OF NEBRASKA
<br />f.
<br />a
<br />DATE 'OFISSLIAN
<br />2/14/2023'•
<br />LINCOLN, NEBRASKA
<br />202406439
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />! DECEDENT'S -NAME iffiest, Middle, Last, Suffix)
<br />Russell Rathje Schultz
<br />CERTIFIQATE OF DEATH
<br />4. car AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Waterbury.:. Con.ne.Cticut
<br />$0910EOURITY:NUMBER
<br />a0-5247285
<br />Sb. FACILITY -NAME (If tea# institution, give street and number)
<br />The.: Heritage at. Sagewood
<br />Sc. CITY OR TOWN OFDmTH (Include Zip Code)
<br />Grand Island 68803`
<br />Si. RESIDENCE.STATE
<br />Nebraska
<br />9d. STREET AND NUMBea4
<br />2d10.1N Alines St
<br />9b. COUNTY
<br />Hall
<br />10a. MABITALS'!'ATUB ATTIME OF DEATH E Married Q Never Married
<br />Q Married, but separated ❑ Widowed ❑ Divorced Q Unknown
<br />11. FATHER'S-Nl ty E (First, Middle, Last, Suffix)
<br />MiltOn<;::' :SChultz
<br />13. EVER St U.S_ARMEO FORCES? Give dates of service if Yes.
<br />(Yee, No, or link) NO
<br />16 METHOD OF.DISpcsrnON
<br />9ttilats;
<br />[ remotion C] Eaftot4rent
<br />Dftarnidvai' Other (Specify)
<br />5a:. AGE Last Birthday.
<br />(Yrs.)
<br />85.
<br />db. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Be.:PLACE OFDEATH'
<br />NOS_ITAL:'.r1 inpatient
<br />Q ER/Outpatient
<br />Q DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 01172
<br />3. DATE OF DEAT11 (iyltr:.
<br />January,2S4623
<br />6. DATE OF BIRTN'(3to., Day, Yr y'
<br />July 16, 193:7.:;:
<br />OTHER ❑ Nursing Homa/LTC
<br />❑ Decedent's Home
<br />E Other (Spsclfy)ASSI
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />$f. ZIP CODE
<br />68803
<br />`004t4. fEi ClTY`I IAiITS
<br />1:1100.];
<br />10br NAME Of SPOUSE (First, Middle, Last, Suffix) If wife, give maiden natlkr`'`
<br />Sharon Geisler
<br />14a. INFORMANT -NAME
<br />Sharon Schultz
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16d. CEMETERY, CREMATORY OR 0
<br />Grand Island City Cemetery
<br />42.180THER'S-NAME (First,
<br />Erma .::.::: Ftathie
<br />16b. LICENSE NO.
<br />1537
<br />Middle, Maiden Surname)
<br />ER LOCATION. CITY / TOWN
<br />Grand Island
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfe1 Funeral I'4ome :1123 W. 2nd, Grand Island, Nebraska
<br />CAUSE OF DEATH (See Instruct
<br />nd examDles)
<br />1a. PANT I. Enterthe chain of events- .dramas. Injuries, or complications.hst directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular Sanitation whhuut showing the etiology. DO NOT ABBREVIATE. Emer only one cause on a ling. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) dementia
<br />iMM IATE:CAD E:$ final:
<br />difeih#e or]Cinnsithih.re's.:idmtnp
<br />in dfaag.
<br />Sequentially get conditions, If
<br />... any, histanq to tha.i:+uae;listsd
<br />UUNDERIYiNc C TUBE
<br />(diseisl�0'1"injurithal Mitltitw'd
<br />the events resulting In death)
<br />LAST
<br />18 :1 A:,RTe.0
<br />R
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />NIFICANT CONDITIONS -Conditions contributing to the de
<br />29. IF FEMALEt..
<br />�N': annex it.Mthih:);u y.sr
<br />Pte(pfdlldf. &OM* M dRYtR:•
<br />Not.pisgnarmmlut Magna* within 42 days of death
<br />0 Not pregnant, but pregnant 43 days tot year before death
<br />Unknown if.pnpnant wit in the.pest year
<br />TE:OF INJURY ;(Mo. Day, Yr.)
<br />22d. INJURY AT WORK?
<br />OYES „ONO:
<br />h but not:
<br />ultiiig In
<br />21a. MANNER OF DEATH
<br />E Natural ❑.Homicide
<br />Accident OM/Sip Irwsltigetion
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY.
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />. "L:OCA`i'1ON' ' 'STR A NUMBER, APT.NO. CITY/TOWN::;
<br />23i. DATE OF DEATH (Mo., Day, Yr.)
<br />January 25, 2023
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH
<br />Jdf r 30:2023 08:45 PM
<br />diTriflatboat of my tutowtedge, death occurred at the time, date and place
<br />and3due'tp:t(s'Merge) stated. (Signature and Two
<br />Travis S. Haoeman, MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />'YES;; ;;N(i'j;' 0 PROBABLY E UNKNOWN
<br />z
<br />u8
<br />he underlying cause given in PART I.
<br />21b..IF TRANSPORTATION INJURY
<br />Orin lrioperator
<br />`PaaNnger
<br />:• 0:Pedestrian
<br />0 Other (Specify)
<br />14b, RE
<br />,Son
<br />NSISP TO DECrfrIENT
<br />APPRO IMATEaerekvAL
<br />urroot Otealh :.
<br />11, WAS 1610 AL EXIAMNiNER;'
<br />OR CORONEMCONTACTE04
<br />❑ YES ®NO
<br />21 c. WAS AN AUTOPSY PERFORMED?'
<br />YE8 el NO
<br />21d. WERE AUTOPSY FIBOINGE
<br />TO COMPLETE CAUSE OF
<br />❑ YES ❑.,
<br />home, f ri , etrset, factory, office building, construction
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OEDEATB.
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME
<br />2k• Orr the (Elvis o/ examination and/or investigation, in my epinlon dealt; hlatalad#t
<br />the time;. date and place and due to the cause(s) stated, (Signitttint ahtgfpal - ...
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />A YES El NO:.;::
<br />2T. NAME. Tin LEr;.AND ;ADDRESS OF CERTIFIER (Type or Print
<br />1`rauisS.Hagman, MD, 729 North Custer Avenue, Grand Is!
<br />26a. REGISTRAR'S SIGNATURE
<br />Amended
<br />2/14/2023 Item 9d, "232d W. Louise St." To "2410 W. Anna St."
<br />nd, Nebraska; 88803
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicabis if 26a is NO '' YES
<br />28b. DATE FILED BY REGIS
<br />February 1, 2023
<br />
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