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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AM
<br />SYST04 R CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VWAL STA,
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />2/13/2004 200401549 Assl,
<br />LINCOLN, NEBRASKA HEALTH AND H
<br />STATE Of NEBRASKA- WARTMatT OF MALT H AND Htil M Sot,Vl��
<br />VITAL STATISM _ .3
<br />C'.ERTIF'tr-ATE OF nF:ATH
<br />d
<br />i DEC;EMNT I NAME. Fw*1 MIDOLE LAST
<br />2, SEX
<br />`.SW yww
<br />Henry Hans Schultz, Jr.
<br />Kale
<br />February 9,`,2004
<br />€ a. CITY ANG STATE. CAF Til sA* aA.n U.SA_ AtwrlePtaarcr
<br />Sa AGE - Lank &*A*
<br />tNgE # "'M
<br />UNDER 4 DAY
<br />6. DATE OF 'STN+ wow, v+wrtt
<br />3C. NAGS. 0AAAYS
<br />St. t [INNS.
<br />PART b F FEMALE, WAS THERE A 24 AUTOPSY
<br />PREGNANCY Nl TNi PAST 3 MORTW S
<br />q"Yty,.
<br />25. WAS CASE IEFERIEd TO h�DiCAi...
<br />EXAw" OP
<br />Alda, Nebraska
<br />80
<br />Fx
<br />y!6 NO
<br />November 1 1923
<br />'r. SOCIAL SECUPPY WKWA.
<br />YR PLACE OF DERTK
<br />' 24At. DESCRIBE NOW Ni,,fAY OCCURFMO
<br />" Q 2- ✓
<br />507 -38 -5702
<br />[:] EP F1 wrawNrca
<br />So AACRAY•NAM lxm- 11NINNNr1owaNnN1Ana- u*>awt
<br />St. Francis Skilled Care
<br />Q ou IK Oww - S 37 Nara- r
<br />#F.. CCMY. TOWN OR LOCATION OF MATH IN ANMECTY t.M n
<br />Nr COUNTY OF NAT)-
<br />Grand Island l YN ®"a ❑
<br />Hall
<br />s 94 $WSKMACE - STATE a COUNTY 9c CITY, TOVW OR LOCAT11ON
<br />Id STREET AM NUMBER *1cU WgZc COOW IN NNStpE CITY LIWTS
<br />Nebraska Hall Grand Island
<br />630 N. Ave. 688M f -to � NN
<br />fa RACE � 4°#1.¢,. w"a 34". Amersto maw
<br />TT. R K:ESrT" tN¢. i w" Gomm N o
<br />4Z. (X MAt>NAW M `AM)OW 3 i�:.. iaWOF SPOU% d�wil. grNN+r7,BMMh r4M�!y
<br />(�
<br />White
<br />� American
<br />owoRCEO Lorraine Schroeder
<br />4#6 . USUALOCCUPATKkt 'G ,aas+Y awrA*OV A*"MW
<br />INN KM OF N TRy j IS. eDUiCAT+ON
<br />at*VwV thwlr Farmer
<br />Agriculture.. �ls+ T:�D•tn. CaNN9o+:+:t -< ' -`
<br />4N- f+c4e�n•NA� �a .wuexx uw� � .,.,,.,�. .„w �,..�s �....�.. �.....�....
<br />Henry Schultz, Sr. Amanda Rohmeder
<br />IN. WAS EVER NN U.S. D Ft 7.. 49R MAW
<br />€ye& -0 waki 1N yM. ww we (lI%$ d NN4MClN1
<br />No I Lorraine Schultz
<br />I% NW 1T M+VLM ADDRESS WREST CR D. Na- Ceri' OR TOWN STATE. an -
<br />630 N. Custer Ave., Grand Island, Nebraska 68803
<br />21&t1ETtMOF° 00POSTON ZU DATE ire CEMETETEPy O"a&MATcwV YAW
<br />#1071 etruary 12, 2[11#4 Grand Island City
<br />t3NERAi- NOW MAW - 2411. CEMETERY CA CREAAATORV LOCA.TNDk CaTV 041**% STATE
<br />All Faiths Funeral Home 0 ❑°` Grand Island, Nebraska
<br />226 FUNERAL NOIRE. ADOWASS 49TASfT OR RF,3 NO, CITY CST TOW S ATE BM
<br />.2929 S. Locust St., Grand Island, Nebraska 68801
<br />21. IMME IATE CAUSE WATER ONLY ONE CAUSE PER LOW FOA=M. €iN, AND ico kNNna? CdANNNaY+ oeww axvi raaaN�-
<br />PART
<br />.r, I j 4.k
<br />OLe TO. OR AS A CON'SEOVENM OF
<br />t
<br />C
<br />Ye,-,)-
<br />WE TO, 09 AS A COW4FOUENC E OF
<br />PRAT { 1KA 7 CON*T cw**wwq w Na/ dNNN4 N4A Am 110a II
<br />PART b F FEMALE, WAS THERE A 24 AUTOPSY
<br />PREGNANCY Nl TNi PAST 3 MORTW S
<br />25. WAS CASE IEFERIEd TO h�DiCAi...
<br />EXAw" OP
<br />3 }
<br />fAgK to-54 YON NG S '.. -
<br />Fx
<br />y!6 NO
<br />Mb DATE OF 04A)AY [ANN, AW.. W,p
<br />2NC. wxAOF "AJAY
<br />' 24At. DESCRIBE NOW Ni,,fAY OCCURFMO
<br />f7
<br />Suad[ t7 PW.ON
<br />21NN. IN4AlAT' AT V1CiRiC iM. MtM -. 41wn.. aNMk. taeN,X
<br />24 C4CATK%N STREET 1711 A.F .. NX2,
<br />C?Ty QP 1{3W:s 5TA:E
<br />27a DATE OF CEATN fi k
<br />4w n#
<br />286. OAT£ SOME# film.. DA,
<br />1e" A4 TIME OF OEATkt
<br />j February 9, 2004
<br />��
<br />_ M
<br />DATE SIGNED fw LAW. V, Ire TIME OF OEATIR ¢
<br />04:10
<br />: 28C PAONOUNCEC DEAD it* 2Ary: rre � PAC ;atNNCE€3 DEAD ttaznv
<br />: 2t►. 00 ow No" d �e am Cw , ar e4p Oman 4NaU++➢K CLYaId at
<br />8�l�oY
<br />2TE! T rt a'.t bMt 9t dN1+ A17^ 7 e�rre �pypa�t 4i-V to vw e
<br />_ rNU7KfA wit / r w� J \
<br />t ,
<br />t E+N mow oat P W4 *A a NO C*A�" 001
<br />r -Nall
<br />3 YES +3 NQ El UNKNOi" YES NC - El YES ,n, } !K3
<br />Wit. NAME ANO AD(NIESS €:F G£ilT1F#E# EPNYjIC}fYl, CONC#aEPS PHY$K'1:, N � COUNITY ATT'CNIIaEY) tTvM►tx PMt� [(( `�.
<br />Chad W. Vieth, M.D., 2116 W. Faidley Ave., Grand Island, NE 68803
<br />iA`#. q[ TIWW 5!D DATE. PLED By itE{' GTRAP Daw yr (
<br />FEB 12 2004
<br />,EX. A
<br />
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