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CED N F <br />E: tFlri <br />aUt <br />PNXIafNvS,; ; tii,.`:'•: 'a �tt1111111n)r .... .< C ran„•,. '. ,nllfllln , ;•: <br />�irvavL3�m,:lll(iR.v, <br />innhii't 'nqd� <br />STATE OF NEBRASKA <br />..hWda.W,>' � zstE471111yf1tldJg•>, _�. ;<%tAih'PlC,y`ro�•' +self/19'APYfC1W1"> <br />IHU{flXdXn` ' <br />ED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT R <br />tECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AN <br />2FFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />^fl262587 <br />)0•4 <br />SARAH BOHNEN <br />ASSISTANT STATE BEGl7"bl <br />DEPARTMENT OF HEALTI% <br />AND HUMAN SERVICES' <br />--STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />CERTIFICATE OF DEAT1i <br />st, Suffix) <br />Y, QR FOREIGN COUNTRY OF BIRTH <br />b. COUNTY <br />Hall <br />J MaNever Married <br />© Divoresd p Unknown <br />5a. AGE - Last Birthday <br />(Yrs.) <br />75 <br />6b. UNDER 1 YEAR <br />8a. PLACE OF DEATH <br />HOSPITAL Inpatient <br />p ER/Outpatient <br />0DOA <br />9c. CITY OR TOWN <br />Grand Island <br />2. SEX <br />Male <br />5c. UNDEEC 1 DAY <br />OTHER ®Nund <br />p Dtic« <br />p othM <br />6d. COUNTY OF DEATH <br />Nance <br />90. APT. NO. <br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) Ifvlifs <br />Rita Schroeter <br />14a. INFORMANT -NAME <br />Rita Kaul <br />tUNERAL DIRECTOR SIGNATURE <br />1ley D Sheridan <br />t2. MOTHER'S -NAME (First, Middle, <br />Edith McAvoy <br />15b. LICENSE NO. <br />1439 <br />ancw"•" "X `'"' ""' 16d CEMETERY CREMATORY OR OTHER LOCATION CITY / <br />d Qaa} is r clry) ' T°'1'" <br />Central Nebraska Cremation Services Gibbon <br />fiERA HO YiIktiNall:> Nq MEWING ADDRESS (Street, City or Town, State) <br />2929 S. Locust Street, Grand Island, Nebraska \ <br />CAUSE OF DEATH (See Instructions and examples <br />. #nlsiMi +Q(i Veil; yries, or conl$cedons4hat directly caused the death. DO NOT enter terminal events such as tartlet ar,Mt, <br />4rlt t M, . vAthost shating the etiology. DO NOT ABBREVIATE. Enter only one tau$e on a line. Add addr onal linos r<mammy. <br />q:.INNg►EDIATE CAUSE: <br />i's Disease <br />A CONSEQUENCE OF: <br />nia <br />CONSEQUENCE OF: <br />A CONSEQUENCE OF: <br />IGNIiq¢jk l"kiwpNQ/ rlON84;onitl8ons contributln9 to the death but not resulting in the underlying cause given In <br />ItlGftt t zdlsk t.s, coroftary artery disease, chronic heart failure <br />s to 1 year baton <br />21a. MANNER OF DEATH <br />Natural, p Homicide <br />0 Accident p Petting Investigation <br />Suicide 0 Could not be determined <br />OF INJURY <br />22c. PLAOE OF INJ <br />OCCURRED <br />21b--.iF TRANSPORTATION 1 <br />_EyDnwr/Operator <br />0 Passenger <br />p Pedestrian <br />El Other (Specify) <br />Y-At horns,farm, street, factory, office <br />APT.NO. CITY/TOWN STATE <br />2aa TIME 0*DEATH <br />.1\1:30 PM <br />al the thus, date end plan <br />Me) <br />PRQBA$LY © UNKNOWN ® YES 0 NO <br />f7F' TI R (Type or Print <br />APRJ& e50 $ Park St, Genoa, Nebraska, 68640 <br />ATUt;cE <br />24a. DATE SIGNED (Ma„ Day, Yr. <br />24c. PRONOUNCED DEAD (Mo„ 1 <br />.On the bola of examination andlor Inw <br />the time, date and pace and due to the <br />DATE Rl,ED <br />February 2 <br />DA <br />Fe <br />