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i%?�.. .;df'sp,, '.. z<t3.i/i!%�11WfDiSay" '0sa8h45yPit.So:•-<rgtg411A�1�1,f.1.IPJ5gex: ;vgrt44h�d�Jss <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 />