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s <br />WHEN THIS COPY CAMMS T11E RAISED SEAL OF THE NEBRASKA HEALTH ADW h1UMAN SERVICES <br />SYSTEM IT CERTTF/ES T14E BELOW TO BE A TRUE COPY OF THE ORIGNVALAEMWM ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEA4 VITAL SEVIQN WCH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE <br />JAN 3 12002 200411127 7= <br />SS/h FE TRAR <br />LINCOLN, NEBRASKA HEAL MAND HUMAN S(EAVI00 SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AN6iWM-AN V(CgI[JA-NC SuUn 7 O 9 <br />VITALSTATISTft - _ U U <br />CERTIFICATE OF D&i'I'u == - <br />1. DECEDENT-NAME FIRST MIDDLE LAST - =' <br />_p.Jt -�= - = <br />3. DATE OF DEATH /Monm. Day Year) <br />Sara Jane Schnuelle <br />Female <br />January 27, 2002 <br />4. CITY AND STATE OF BIRTH (anof,io U.S.A.. namecounrry/ <br />5a. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH fMonflr. Day Year) <br />(Vrs.l 5b <br />MOs. DAYS <br />5c. HOURS' MINS <br />Kearney, Nebraska <br />72 <br />I <br />July 13, 1929 <br />7. SOCIAL SECURTIY NUMBER <br />Sa. PLACE OF DEATH <br />506-28-7366 <br />HOSPITAL: ❑ Inpatient OTHER: ® Nursing Home <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY - Name (Hnor insidulkw. give sheer and number) <br />Tiffany Square Care Center <br />❑ DOA ❑ Other /Soecdyi <br />Bc. CITY. TOWN OR LOCATION OF DEATH <br />Bid INSIDE CITY LIMITS <br />fie. COUNTY OF DEATH <br />Grand Island <br />Yes © No ❑ <br />Hall <br />9a. RESIDENCE - STATE <br />9b, COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER /Including lip Code) <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />1733 S. Blaine 68803 <br />Yes © No ❑ <br />10. RACE - (e.g.. While. Black American Indian. <br />11. ANCESTRY (a g.. Italian. Mexican. German. etcl <br />12. ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE 1/1 wrie give maiden name/ <br />etc.) (Specify) <br />White <br />(Specify( <br />American <br />NEVER DIVORCED <br />MART <br />Robert K. Schnuelle <br />14a USUAL OCCUPATION /Give kind of work done during most 14b. <br />KIND OF BUSINESS INDUSTRY <br />15 EDUCATION (Specify only highest grade completed) <br />of working life. even 11 red) <br />Bookkeeper <br />Various Offices <br />le tar Saco ary 10 -121 C e It -a or 5�1 <br />I tT uran 2 Tears <br />16. FATHER - NAME FIRST MIDDLE LAST <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />�17 <br />Lawrence Krebs <br />Marvel Gherman <br />18. WAS DECEASED EVER IN US ARMED FORCES? <br />19a. INFORMANT NAME <br />(Yes- no or unk.) IIf yes give war and dates of services) <br />No I -- - - - - -- <br />Shari Schnuelle <br />19b INFORMANT MAILING ADDRESS (STREET OR FIT D NO.. CITY OR TOWN. STATE. ZIP) <br />3033 W. Capital Ave. #29, Grand Island, Nebraska 68803 <br />20. EMBALMER - SIGNATURE 8 LICENSE NO <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY - NAME <br />Not Embalmed <br />❑Renal ❑Removal <br />Jan. 28 2002 <br />Westlawn Cremator <br />22a. FUNERAL HOME - NAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Livin ston- Sondermann F.H. <br />71 Cremation ❑Donal <br />r Grand Island, Nebraska <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.O. NO CITY OR TOWN. STATE, ZIP) <br />601 N. Webb Road, Grand Island, Nebraska 68803 -4050 <br />23. IMMEDIATE <br />CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. 0. AND (cl) Interval between onset and death <br />PART <br />I /� y1.1T,� <br />10 �oYi <br />lal <br />IX " 1 <br />DUE T0, O AS A CCf4SEOUENCE OF Interval between onset and death <br />(b) 1 <br />DUE TO. OR AS A CONSEQUENCE OF I Interval between onset and death <br />I <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />PART <br />111 IF FEMALE. WAS THERE A 24. <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />IN THE PAST 3 MONTHS? 1_ <br />EXAMINER OR CORONER? <br />(Ages <br />10 -54) Yes 0 No <br />Yes No <br />Yes F No <br />26a. <br />26b, DATE OF INJURY (Mo.. Day. Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />❑ Accident F] Undetermined <br />I <br />- <br />M <br />Suicide Pending <br />26e, INJURY AT WORK <br />26f. PLACE QF, INJURY - At Ian, farm. street. factory <br />;k <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />❑ Homicide Investigation <br />Yes No <br />❑ ❑ <br />,AC bxlMng, etc. /Specify <br />27a. DATE OF EATH (MO Day. Yr.) <br />O Z <br />28a. DATE SIGNED /MO.. Day Yr.) <br />28b. TIME OF DEATH <br />a <br />M <br />i G > <br />27b. DATE SIGNED ( . Day Yr) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD (MO.. Day- Yc/ <br />28d. PRONOUNCED DEAD /Hour) <br />4 <br />12� 1 <br />C� A M <br />- O <br />g <br />M <br />z� <br />27d T the best W my knowledge. death occ 'red at the time, date and place and due to thE- <br />28e. On the basis of examination and /or investigation, in my opinion death occurred at <br />° <br />° ° ° <br />~ <br />cause(s) stated. ((\/ _ <br />° a <br />the time, date and place and due to the cause(s) stated. <br />(Signature and Title ) ► <br />(Signature and Title ) ► <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a <br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b <br />WAS CONSENT GRANTED' <br />1-1 YES tK NO F_] UNKNOWN <br />❑ YES ONO 1 <br />11 YES 1410 <br />31 AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( /Type or Pnm)1 - <br />+ Pems. 0- (- S 4ocWv-na n - ml� - 2tiLAIA Fo Ave cc d Ts(clod' � <br />32a. REGISTRAR 11 <br />321. DATE )FILED BY REGISTRAR (MO. Day. Yr.) <br />JAN 30 <br />U W <br />If <br />