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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A RU .COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMINT OP.INALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL LSITORY FOR"
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />SEP 121986
<br />LINCOLN, NEBRASKA
<br />202500208
<br />STANLEY 5 , ` 0(iPER,, DT
<br />4.
<br />BUREAU OF VI STI $T1,S
<br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH -4_
<br />DECEDENT —NAME FIRST MIDDLE LAST
<br />Ellen Ione Schoenstein
<br />SEX
<br />2 Fmale
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />3. 8-26_
<br />RACEWhite, Black, American
<br />ORIGIN/DESCENT (e.g., Italian, Mexican,
<br />RicthdayUNDER'1
<br />YEAR I UNDER 1 DAY' DATE Of BIRTH (Mo., Day, Yr.)
<br />-(e.g.,
<br />India��RI� (Sp ify)
<br />4 tW[L�L
<br />German, etc.) Specify)
<br />s American �V
<br />(Yrs.)
<br />60 45
<br />OS. ; DAYS
<br />HOURS : MINS.
<br />�,
<br />,.Feb 16, 1941
<br />CITY AND STATE OF BIRTH (H not in U.S.A.,
<br />"TIU 'b[ ll, Nebraska
<br />CITIZEN Of WHAT COUNTRY
<br />9 USA
<br />MARRIED, NEVER MARRIED,
<br />WIDOWED, DIVORCED (Specify)
<br />,D Married
<br />NAME OF SPOUSE (If wit*, giw maiden name)
<br />,, Thomas Schoenstein
<br />SOCIAL SECURITY NUMBER
<br />1z 505-52-6668
<br />USUAL OCCUPAT
<br />ofworkin ife, own
<br />13aouswe
<br />ON (Give kind of work done during most
<br />' fired)
<br />KIND OF BUSINESS OR INDUSTRY
<br />,3b,Own Home
<br />COUNTY OF DEATH
<br />,4a. Douglas
<br />CITY, TOWN OR LOCATION OF DEATH
<br />14b. Omaha
<br />INSIDE CITY LIMITS
<br />(Speci�y es or No)
<br />lk. Yes
<br />HOSPITAL OR OTHER INSTITUTION — Nome (If not in either,
<br />giwy�. atand numL�er)
<br />14d University Hospital
<br />IF HOSP. OR INST. htdicore DOA,
<br />Outpatient/Einar. Rm., Inpatient (Spocify)
<br />14e, Inpatient
<br />RESIDENCE — STATE
<br />Nebraska
<br />iSe.
<br />COUNTY
<br />Hall
<br />15b.
<br />CITY, TOWN OR LOCATION
<br />, errand Island
<br />STREET AND NUMBER
<br />,sd.1322 Sylvan
<br />INSIDE CITY LIMITS
<br />(sp.cifyr.tarNa)
<br />,Sg.Yes
<br />FATHER —NAME FIR
<br />16.Harry
<br />T MIDDLE UST
<br />-- Alber
<br />MOTHER —MAIDEN NAME FIRST MIDDLE LAST
<br />„ Rhoda -- Orman
<br />WAS DECEASED
<br />(Tea, n or nnh)
<br />16O
<br />EVER IN U.S. ARMED FORCES?
<br />(If yes, give wor and dates of sorice)
<br />I
<br />INFORMANT —NAME —RELATIONSHIP —MAILING ADDRESS (STREET OR R.f.D. NO., CITY OR TOWN, TAT II►)
<br />Nebraska 8 01
<br />19 Thomas Schoenstein: Husband: 1322 Sylvan: Grand s and
<br />BURIAL, Cremation, Removal
<br />20a.Cremation
<br />DATE
<br />20b.8-28-86
<br />CEMETERY OR CREMATORY -NAME
<br />20c.Forest Lawn CrematoryQ�$
<br />LOCATION CITY OR TOWN STATE
<br />god Omaha, Nebraska
<br />EMBALMER —SSSIGNATU B LICENSE NO:73
<br />2 � �
<br />FUZ,IT•E.�TRAL HORMn p( ce"n "LQ tut (SIREataD, : TOrN, STATE, ZIP) �080�
<br />'J A 1--BCiut er-(iect es : 11 W 2n ((jjrand Island, N
<br />22.
<br />►
<br />e best of kn e, «nth ru ti te an • and a to tM
<br />awg(s) stated. �/I
<br />23a.(Sfgnevre end Title) / Yt ♦
<br />To bo Complead by
<br />CORONER'S ►HYSICIAN,
<br />or COUNTY ATTORNEY
<br />only.
<br />On Me bads of .nomination and/er investigation, in my opinion death occurred at
<br />Ow timdote and place end duo to the covaeb) stoma.
<br />e, 24a. (Signature and Title)
<br />iy
<br />r
<br />DATE SIGNED (Mo., Day, Yr.)
<br />-- —(.—'
<br />23b.M
<br />HOUR OF EATH
<br />23c. 1 s : / S-
<br />DATE SIGNED (Mo. Day, Yr.)
<br />24b.
<br />HOUR OF DEATH
<br />24c. M
<br />f
<br />a
<br />DATE Of DEATH (Mo., Day, Yr.)
<br />r, .2 /
<br />23d. es) b a n
<br />PRONOUNCED DEAD
<br />(Mo., Day, Yr.)
<br />24d.
<br />PRONOUNCED DEAD (Hour)
<br />24e. M
<br />NAME AND DDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (type or Print)
<br />�o `A E.. r a'«.�.(9 s a 0', UN t L 9-A� J I— 6 e �,
<br />REGISTRAR e / e dL
<br />9� / 2ja p'T.
<br />,J, 26o.(Signetwel� ♦ %
<br />DATE RECEIVED BY REGISTRAR�Mo., Day, Yr.)
<br />A U S 2 8 1986
<br />26b. _ , , J
<br />27. IMMEDIATE CAUSE
<br />PART
<br />(o)
<br />(b)
<br />(e)
<br />PART OTHER SIGNIFICANT CONDITIONS —Condition. contributing to death but not related
<br />►I
<br />ACCIDENT, SUICIDE. HOMICIDE, UNDE?..
<br />OR PENDING ITTIGATION. (Specify)
<br />30a. 0
<br />DATE Of INJURY (Mo., O. Yr.)
<br />30b.
<br />' w't_
<br />(E R ONLY ONE CAUSE P()t LINE fOR (o►, (b), AND (c
<br />U� Sp rAiNvt-L
<br />DUE TO, OR AS A SEQUENCE I
<br />C Tyl• �1nt�i 0 i
<br />DUE TO, OR AS A QONSEI?UENCE OF:
<br />Z. GV,44-cc(,1st C.c,Lik,CClr'
<br />PART III. IF FEMALE WAS THERE A
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />HOUR Of INJURY
<br />PLACE Of NJURY— At home, loan, singe, factory.
<br />officer building. ate. (Specify)
<br />30f.
<br />AUTOPSY
<br />(Specify yespr No)
<br />Yes 0 No SE 0
<br />At
<br />DESC HOW INJURY OCCURRED
<br />30d.
<br />Interval betaireoi ., end deoM
<br />( it tk
<br />i Interval befaete *mot end deo*
<br />1
<br />WAS CASE REF MEDICAL
<br />(SEA , i
<br />OR Ce or�OROSKI
<br />29. Aye,
<br />STREET OR. R.F.D. No. CITY OR TOWN STATE
<br />INJURY AT WORT(
<br />1 (Specify Yoe or No)
<br />30e.
<br />30y_
<br />
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