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UNCOLN,NE�RASKA - HEALTH AND H_�4 SERVICES SYST�1__ <br /> TATE OF NEBRASKA-DEPARTMENf UF HEALTH AND HUMAN SERVI[�5 AND..SUPfOIt'L-=_ <br /> V1TAL STATIS7TCS -_- =- -_" ' - . <br /> _ _._,.__..__- . - <br /> CERTIFICATE OF DEATH =--= --_-= __- -=- <br /> 1.DECEDENT-NAME FIRST MIDOLE LAST 2.SEX -__�.3.DALE_QE-�e'�H /Abnth.Day.Vsul <br /> Mervin NMN Schroeder, Sr. Male �August 17, 1998 <br /> 1.CITV AND STATE OF&RTH /Hnol'n U.S.A..n�m�eountryl � Sa.AGE-Lest BirtlWay UNDER 1 VEAR UNDER 1 OAV 8.DATE OF BIRTH IA1wtlr.Day.Yaer) <br /> . �Vry,l Sb.MOS. OAVS Sc.HWRS' MINS. <br /> Alda , Nebraska 90 ' June 25, 1908 <br /> . 7.SOCIAL SECURTIY NUMBEFi Ba.PIACE OF DEATH <br /> 506-09-4513 HOSPRAL: � �n0atieM O7HER � NursmgNOma <br /> � _- <br /> BD.FApLITV•Nams /MndrnsfilWinn,yiwsbsN�nOnunWx/ � EH Oulpetlsnl � Residence <br /> , Saint Francis Medical Center ❑ °0A ❑ a�"S°B"w, <br /> &.CITV.TOWN OR LOCATION OF DEATH 8tl.INSIDE CIN UMITS Ba.COUNTV Of DEATH <br /> Grand Island rss �X r� ❑ Hall <br /> 9a RESIDENCE•STATE 9b.COUN7V 9c.CITV.TpWN OR IOCATION 9d.STqEET ANO NUMBER pntWG�ny Zip Codel 9!INSIDE CITV LIMITS <br /> Nebraska Hall Grand Island 715 W. Stolley Park Rd. Y« X� No❑ <br /> f0.RACE-le.q.,W�de.BUck.Americen Indian. t 1.ANCESTRV le.g..Italian.Mec�can.Gsrman.elci �� �2.❑MARRIED �WIDOWEO� 13.NAhAE OF SPOUSE !N w�h.grve mamsn nsms) � <br /> "`,�s0°""� White �S0"`�"� German NEVEH DIVORCED Gertrude Meinke <br /> 1ta.USUALOCCUPATION (Grvekinddwakdwisda'wgmat( llb.KINDOFBUSINESSINDUSTRY �j�1 15.EDUCATION �Spec�lyonWhqhsttgrWacompstW) <br /> Wworhirgli/e.swnHrofirMl �� ! EbmeMary a S�eonAary 0-t21 Cdlpe It-1 or 5•� <br /> Feed & Seed Salesman Grain Elevator Co-o 8th Gra�e <br /> 16.FATHER•NAME FIRST MIDDIE UST 17.MOTHER FIRST MIDDLE MAIDEN SURNAME <br /> ' Otto � Schroeder Bertha �N Richert <br /> 18.WAS DECEASE�EVER IN U.S.ARMED FORCES7 19a.INFORMANT-NAME � � <br /> �VSS.no.a unk.� W Yea.grve war antl Oaus d ssrvieasl <br /> No -------- Wayne Schroeder <br /> 1Pb.INfORMANT MAIUN6 ADDRESS ISTREET OR R.F.D.NO..CITY OR TOWN.STATE.ZIPI <br /> 9 W. Phoenix, Grand Island, Ne. 68803 <br /> LMER SIG RE 6 LIC E NO. �� / 21 a.METMOD OF DISPOSIT�ON 21b.DATE 21a CEMETERV OR CREMATORV�NAME <br /> �D <br /> �e�,, �R.,��a, Aug. 20, 1998 Westlawn Memorial Park <br /> 22a.FUNE lIOME-NAME . Yld.CEMETERY OR Cf�MATONV LUCATION " " CITV OR TOWN STATE <br /> Livingston-Sondermann F.H. ❑�'°"""°" �°on"'°" Grand Islar.d, Nebraska <br /> 22p.FUNERAL HOME ADORESS ISTREET pp R.F.D.NO..CITV OR TOWN.STATE,ZIPJ . � <br /> 601 N. Webb Road, Grand Island, Ne. 68803-4050 <br /> 23. IMME TE CAUSE IEN7ER ONIV ONE CAUS PER LINE FOR lal.ID�.AND�c�) i Inlarval Delwssn msM antl Ceaih <br /> ✓PART <br /> ' /� � lal , � ��' 1 n ` �Z ` i.� <br /> � DUE T0.OR AS A CONSEOUENCE OF i Intsrvai Deiwasn omM an0 tleam <br /> i <br /> (b� � - <br /> DVE TO.OR AS A CANSEQUENCE OF: I IMSrvaI belwssn onael an0 Aeatl� <br /> . I <br /> I <br /> (�� I <br /> OTHER$IGNIFICANT COND�TIONS•Cmdilions WnVibWinp b IM OeaM Dul nd relateE PART 111 IF FEMALE.WAS THERE A 2�.AUTOPSV 25.W AS CASE REFERREO TO MEOICAI <br /> PART � PREGNANCY M THE PAST J MONTHS? X E%AMINER OR COHONER? <br /> tl <br /> - �Agos 70-541 Ves No Vas No Vse NO <br /> 25a, 260.DATE OF IWURY (MO..Day.YcJ 28t.HOUR OF INJURY 26d.DESCRIBE HOW IWURV OCCURRED <br /> � Acti08M � Und8lerm�neA M <br /> � SuiciOe � PeMmg 26s.INJURV AT WORK 26t.PU�CE QF INJeU�HV%�.larm,sireN.lacWry 26g.IOCATION STREET OR R.F.D.NO. CITV OR TOWN STATE <br /> oNic buNdn¢ <br /> � � FbmiciAe InveslpaUOn Vss� No� . <br /> 27a.DATE OF DEATH /Ab..Day.Yr.J 28a.DATE SICNED /Ab..DaK y�1 28b 7iWE OF DEATH <br /> � 31 `� � . S�� M <br /> �� 27b.DATE SIGNED lMo..OaY_Yi.l 27c.TIME OF DEATH ��y 2Bt.FRONOUNCED DEAD /Ab..Day.Yr/ 28d.PRONOUNCED DEAD /HOwI <br /> �� �- .. � - 8 � �o � ~�� M <br /> 8� M $ <br /> 27E.To the best d my knov�aAg�dse�occurred at the te an0 place and ro the � 2Be.On Me Daais d sicamin�tbn anC�a irwes�pa�bn,in my opnion tlaatn oeeurted at <br /> ,cyusalsl sutetl. ' \ ~ �+ tM fime.daN and Wace arW Aua b Ms uuaelsl sW W. <br /> �C J � �Z���.� �.. M. wro and Tine <br /> (Si lure and Titla <br /> 29.DID TOBACCO USE CONTR18 TE TO THE OEATH7 3Qa MAS ORGAN OR TISSUE DONATION BEE CONSIDERED? 30.b WAS CONSENT GRANTED7 � <br /> . � � VES �W�- � UNKNOWN � � YES �,N� � � VES NO <br /> 31.NAME ANO ADD�ESS OF CERTIFIER IPHVSICIAN,CORONER'S PHYSICUN OR CAUNTV ATTORNEY� /TyeeW P�fl" <br /> Dr. John J. Cannella M.D., 72 N Custer, Grand IsZand, Ne. 68803 <br /> 72a REaSTMp 32b.DATE FILED 8V AUG 21 Y y'� <br /> . <br /> � <br />