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<br />WHEN THIS COPY Ci THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />�. SYSTEIK IT CERTIFJES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REG0062WWE4MTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST /0fiW_1ti)IIF,�1? ICFtlS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />O r..
<br />1!A 000I SEP 7 2001
<br />200111996
<br />ASSI;�TANT3f`ATE.;&GI$TAPR=
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN $ERVIC $)'S EI
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SER iC F[N 3CE.-AD_ �3JpPORT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH (� {vj `�' 6
<br />.._.,., 1,,.... .,I..,.- .....,� �.,� �,....
<br />I
<br />I, -'1^
<br />-
<br />I —yr. —H n�,r,U.iI I III I
<br />Marjorie Emma Scheel
<br />IFemale
<br />September 2, 2001
<br />d CITY AND STATE OF HIRTH 111 no(in USA name countrl.l
<br />-
<br />5a AGE Last Birthday
<br />UNDER t YEAR
<br />I UNDER I DAV
<br />- — -
<br />6 DATE OF BIRTH :Month. Dav tear)
<br />DUF TC OR AS A CONSEOIJENCE OF
<br />Ic)
<br />Grand Island, Nebraska
<br />1Vrs.
<br />82
<br />September 8, 1918
<br />Sb MOS DAYS
<br />is HOURS MINS
<br />25. WAS CASE REFERRED TO MEDICAL
<br />7 SOCIAL SECURTIV NUMBER
<br />ga I+I. ACE OF DEATH
<br />�'
<br />543 -01 -3810
<br />HOSPITAL ❑ Inpatient OTHER ® N_,h, Hbme
<br />- --
<br />(Ages 10 54) Yes No
<br />Yes NO
<br />❑ ` -R Outpatient ❑ Res�,,,c
<br />8b. FACILITY -Name flf nol,n,,hlunon . give'beetaria number) -
<br />261, DATE OF INJURY III Day. V.
<br />Beverly Healthcare Lakeview
<br />❑ DOA ❑ On" 5:.r•,,,,-
<br />8c CITY TOWN OR LOCATION OF DEATH
<br />Ed INSIDE CITY LIMITS
<br />Be COUNTY OF DEATH
<br />Grand Island
<br />Yes ❑ No ❑
<br />Hall
<br />M
<br />9a RESIDENCE � STATE 9b COUNTY
<br />9C CITY. TOWN OR LOCATION
<br />91 STREET AND NUMBER fn q,d�nq z,n �-o,I,6880 1
<br />1 9e INSIDE CITY LIMITS
<br />26f PLACE OF INJURY At home. farm street. factory
<br />Nebraska Hall
<br />Grand Island
<br />216 E. Stolley Park Rd.
<br />I Yes © No ❑
<br />oX,ce Dudtl,ng. etc !Spec, I
<br />10 RACE- Ieq.Whne Black Ame.r,canlnd,an
<br />11, ANCESTRY in q. Italian. Mexican. German etc'
<br />12. © MARRIED ❑ WIDOWED
<br />m
<br />13 NAME OF SPOUSE Wwife q,,e aiden namel
<br />etc IISOecfyl
<br />White
<br />ISOec`vI
<br />American
<br />❑N O
<br />EVER DIVRCED
<br />MARRIED
<br />Lawrence J. Scheel
<br />tba. USUAL OCCUPATION /Give kind of work done during nos)
<br />1 db KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (Spec,ly only h,ghest grade completed)
<br />28th TIME OF DEATH
<br />of working life. even If retired/
<br />Homemaker
<br />Domestic
<br />Elementary or Secondary '.0 121 College 1 d 0, i
<br />10th Grade
<br />16 FATHER -NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />i
<br />William _ - - Blaise
<br />Wilhelmena Knefelkamp
<br />28d. PRONOUNCED DEAD /How!
<br />IB WAS DECEASED EVER IN U.S. ARMED FORCES' 19a INFORMANT - NAME
<br />I ,ve
<br />(Yes n( 1 ,., ... 41 yn5 q war and Jae, 01 ServiCeii '.
<br />No --- - - - - -- Lawrence Scheel
<br />g
<br />-
<br />19b INFORMANT MAILING ADDRESS (S TREET OR R. F D NO CITY OR TOWN STATE -ZIPI
<br />_o
<br />216 E. Stoiley Park Rd., Grand Island, Nebraska 68801
<br />M
<br />20 E ALMER SIGNATURE 8 LICENSE NO
<br />21a METHOD OF DISPOSITION
<br />21b DATE
<br />F2lcCSEMETERYORCREMATOHY NAME
<br />,La.4'� ti. Catl( et','Xif
<br />O Burial ❑ Removal
<br />Se t. 6, 2001
<br />tlaw_n_ Memorial Park
<br />IS, nature and Title) -
<br />22a FUNERAL HOME - NAME
<br />21d CEMETERY OR CREMATORY LOCATION ITV OR TOWN STATE
<br />_
<br />Livin stop- Sondermann F.H.
<br />❑Gemaoon El Duration,
<br />Grand Island, Nebraska
<br />GRANTED'
<br />_
<br />22b FUNERAL HOME ADDRESS (STREET OR R.F D NO CITY OR TOWN. STATE. ZIPI
<br />X ❑ YES NO
<br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050
<br />I- I- - - a, —r, tun interval between onset ano o.�a•�
<br />,rPART
<br />lal
<br />DUE TO. OR AS A CONSEQUENCE OF
<br />Interval between onset and deals
<br />DUF TC OR AS A CONSEOIJENCE OF
<br />Ic)
<br />Interval between onset r;N..
<br />OTHER SIGNIFICANT CONDITIO - Conditions contributing to the death but n elated PART
<br />PART
<br />III IF FEMALE. WAS THERE A
<br />2d AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />_ / PREGNANCY
<br />II ✓C.. �`^-- /�/G n_, 7! -��^ �.,L���.' /� .. •. 1.
<br />IN THE PAST 3 MONTHS?
<br />�'
<br />r E %AMINER OR CORONER'
<br />(Ages 10 54) Yes No
<br />Yes NO
<br />Yes _ No
<br />26a
<br />261, DATE OF INJURY III Day. V.
<br />26c HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />nACndenl Undeterm,ned
<br />M
<br />Su,c,de I� Pendlnq
<br />26e INJURY AT WORK
<br />26f PLACE OF INJURY At home. farm street. factory
<br />26g LOCATION STREET OR R F D NO
<br />(;ITY OR TOWN S7a i=
<br />Hom,nde Investigation
<br />Yes �J No ❑
<br />oX,ce Dudtl,ng. etc !Spec, I
<br />-
<br />1
<br />27a DATE OF DEATH /Mo. Day Yr./
<br />28a DATE SIGNED iMO Day. Yr I
<br />28th TIME OF DEATH
<br />-'-September 2,2001
<br />M
<br />Y
<br />i
<br />27b DATE SIGNED rMO. Day. Yr/ 127 TIME OF DEATH
<br />28c PRONOUNCED DEAD fMo.. Day. Ytl
<br />28d. PRONOUNCED DEAD /How!
<br />�
<br />J
<br />g
<br />Se tem M
<br />_o
<br />M
<br />27d. To the best of my knowledge. d h OCCUrrod dl t time, date and place and due 10 me
<br />X
<br />28e On the basis of ezammawth and of investigation. in my opinion death occurred at
<br />° ¢ °
<br />causelsl stated. j
<br />°
<br />the time. date and place and due to the cause(sl
<br />stated.
<br />IS, nature and Title) -
<br />(Signature and Title) ►
<br />_
<br />29 DID TOBACCO USE CONTTR E O THE DEAT '
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'
<br />30.1 WAS CONSENT
<br />GRANTED'
<br />X ❑ YFS lK I NO ❑ UNKNOWN
<br />X ❑ YES NO
<br />(�
<br />L ❑ YES NO
<br />) XI
<br />31. NAME AND ADDRESS OFF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEYI hype dv Pnnf/
<br />D
<br />32. REGISTRAR
<br />1'12rbA FIL .. ay. )
<br />
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