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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD-ON E#,E WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIG,"0C111044WHCH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS = DATE OF ISSUANCE 2 4114 31.�� 9/22/2004 0 0 ASSISTANT' $TATE-RE RAR LINCOLN, NEBRASKA HEALTH AND HUMO SERVICES;I �VAF STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICE$IiNANCE AND W"T VITAL STATISTICS - 4 10090 CERTIFICATE OF DEATH = 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /Month. Day. Year) Helen Maxine Schuett Female September 10, 2004 4. CITY AND STATE OF BIRTH /Ifnof m U.S.A.. name country) Sa. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Year) Cairo, Nebraska (Yrs.) 88 5b. August 23, 1916 MOS. i DAYS 5c. HOURS MINS 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH 506 -28 -7170 HOSPITAL. FX1 Inpatient OTHER. ❑ Nursing Home ❑ ER Outpatient ❑ Residence 8b. FACILITY - Name (Unot instftutiah, give street and number) St. Francis Medical Center ❑ DOA ❑ Other(Spectvi 8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island, 68801 Yes ❑ No ❑ Hall 9a. RESIDENCE -STATE 9b. COUNTY 9G CITY. TOWN OR LOCATION go. STREET AND NUMBER itociuding Zip Code) 9e INSIDE CITY LIMITS Nebraska I Hall Cairo 308 S. Nubia 6882 Yes [j] No ❑ 10. RACE - le.g., White. Black, American Indian. 11. ANCESTRY (e.g.. Italian. Mexican, German, etc) 12. ❑ MARRIED F-] WIDOWED 13. NAME OF SPOUSE /if wife. give maiden name) etc.) (Specify) White (Spec,tyl American NEEVRER DIVORCED Harold Schuett 14a. USUAL OCCUPATION (Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION )Specify only highest grade completed) Elementary or Secondary (0 -12) College 11 -4 or 5.1 of working life, even it retired) Homemaker Own Home g 16. FATHER -NAME FIRST MIDDLE LAST MOTHER FIRST MIDDLE MAIDEN SURNAME Otto Diekman F Lena Voss 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yes. unk.) (If yes, give war and dates of services) Connie Peters N.O 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 4557 E. Chuckwalla anyon Phoenix, Arizona 85044 20. T U 8LI ENS O. ` ` 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME �LMR 4 Burial ❑Removal Sep 14, 2004 Westlawn Cemetery 22a. FUNERAL HOME - ME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel Funeral Home ❑ Cremation ❑ Donation Grand Island, Nebraska 68801 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 411 West 11th St. P.O. Box 126 Wood River, Nebraska 68883 23. IMMEDIATE CAUSE . (ENTER ONLY ONE CAUSE PER LINE FOR (al. (b). AND (c)) I Interval between onset and death PART I � %Gl,)✓- a. Cv#_,e Cj (al ,v, -mali rant DUE TO, OR AS A CONSEQUENCE OF. Interval between onset and death I I (b) I DUE TO. OR AS A CONSEQUENCE OF, Interval between onset mo dean I I (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER? I (Ages 10 -54) Yes F No Yes No a Yes No 26a. 26b. DATE OF INJURY /Mo.. Day. Yr.) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident � Undetermined M ❑ Suicide ❑ Pending 26e. INJURY AT WORK LLqq �� q 26f. Pe building INJURY - At hom , farm, street. factory 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ 27a. DATE OF DEATH (Mo.. Day. Yr.) 28a. DATE SIGNED (Mo.. Day. Yr) 28b TIME OF DEATH September 10, 2004 <Y z �- ¢ M $i r N 9 a c y 27b. DATE SIGNFO (Mo.. Day. Yr) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD (Mo.. Day, Yr) 28d. PRONOUNCED DEAD (Hour! q �Y i�w�o M M g 8 z? °m 27d. To the best of my knowletlge. death occurred at the time, date and place and due to the 28e. On the basis of examination and,or investigation, in my opinion death occurred at ° ° ~ cause(sl stated. ° the time, date and place and due to the causes) stated. (Si nature and Title ► ISi nature and Title) ► 29. DID TOBACCO USE CONTRI TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? [:1 VES NO ❑ UNKNOWN ❑ YES NO ❑ YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY AT70RNEYI (Type or P t) Jeffrey C. King, MD 729 North Custer Avenue Grand Island, Nebraska. 68803 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Mo., pay) 2004 V EXHIBIT "A"