|
• WHEN THIS COPY CARRFES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISV9*7 TR3N, IWHCH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />�
<br />E OF ISSUANCE
<br />ANLBI' S:'tOER
<br />NOV 1 8 2004 200411431, A# STANTSTATE RS0110-
<br />LINCOLN, NEBRASKA HEALTH AA%_HtIMAN SERVICE'&, SYSTAW _
<br />STATE OF NEBRASKA VIAL RT TIST Of FIEIkE3li Q 02279
<br />BUREAU OF VITAL &TATIS71C8 VV
<br />CERTIFICATE OF DEATH, ` ; ,
<br />It DECEDENT -NAME FIgCT "DOE LAST
<br />2. SEX J. DATE OF 59T_14, ,, DM: YaiYj
<br />Harold Fredrick Schuett
<br />Male February 13 =1990
<br />4. CITY AND STATE OF BIRTH 1M not in USA., name CO &y/ ISO. AGE • Laet Smoiday
<br />126c. HOUR OF INJURY
<br />26d. DESCRIBE MOW 04AAW OCCURRED
<br />-
<br />6 DATE OF 9117TH (Math, Qty, Y*07
<br />SD MOS. • DAYS
<br />5c. HOURS WIN
<br />" IYrt.)
<br />once building. etc. (Specify)
<br />Cairo, Nebraska 73
<br />st
<br />a
<br />o27d.
<br />ra. DATE OF DEATH 11146., Day. Yr.)
<br />August 4, 1916
<br />7. SOCIAL SECURITY NUMBER
<br />88. PUKE OF DEATH }Y�
<br />HOSPITAL: 4J kpaaerd 7 C•R'tAltpYste D DOA
<br />524 -12 -0596
<br />1 OTHER D Nu.,wgHOme o Rngence O Caw t. wfy/
<br />6b" FACILITY - Nerne 111 n. insb"*On, O&V s`" ant numbw;
<br />Bc. CM, TOWN OR LOCATION OF DEATH ad. INSIDE CITY LMMTB
<br />N COUNTY OF MAUI
<br />/&Wry YN or Net
<br />$ is
<br />St Francis Medical Center
<br />Grand Island yeE
<br />Hall
<br />1st RESIDENCE • STATE
<br />9b. COUNTY
<br />Bt. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER tmckx&V Z4p Cade)
<br />so tooft city LmTS
<br />31. NAME AND ADDRESS OF CERTIFIER JPHYBICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY)
<br />f i vpe ce Pram)
<br />William L. Fowles MD 716 AlRha St Grand
<br />Nipawy Y- rr mo
<br />Nebraska
<br />Hall
<br />Cairo 308 S. Nubia
<br />yes
<br />10. RACE - I&%, White, 94ck Anwiean Indian, 11. ANCESTRY (e.g..Kalian. Mexican, German, ow.) t2. MARRIED.NEVER MARRIED.
<br />t 3. NAME OF SPOUSE 10 caste p� rttrltr nerN
<br />ex.)1SwoeY) 1Sprcdyl WIDOWED. DIVORCED f*wfyj
<br />white German 4n married
<br />Helen Diekman
<br />14a. USUAL OCCUPATION /6iw kind of work done Owing mold
<br />or workw g We. scan a nered) dj11
<br />t40. KIND OF BUSINESS INDUSTRY -I O
<br />l �v
<br />'
<br />ElsrMrNrY a Secondary (412) i CaMM n.4 er SH
<br />Mechanic _
<br />International Harvester
<br />8
<br />16. FATHER - NAME FI114T MIDDLE LAST
<br />t7 MOTHER -MAIDEN NAME FIRST MIDDLE LAST
<br />Julius (unk) Sctiuett
<br />I Amanda (unk) Claussen
<br />u .- m - rV.rACU rvrRi r lr. xvrVrwM1I - .1 - wyLMf , Am tbJ
<br />(Vee. no, a unk.! (11 yet. Pw wer and dwe of eervicao) .. STATE.
<br />yes WW2 1940 -1946 Helen Schuett- wife -Box 69 Cairo, Nebraska 68824
<br />20L BURIAL, Cremaaon,RlmovaN., I 20b. DATE 20e. CEMETERY OR CREMATORY - NAME 20d. LOCATION CITY OP, TOWN STATE
<br />Donation
<br />Burial Feb 17 1990 1 Westlawn Cemetery Grand Island, Nebraska
<br />21. EMBALMER - SIGNATURE LICENSE NO. 22. FUNERAL HOME • NAME AND ADDRESS (STREET OR R.F.D NO, CITY OR TOWN. STATE, ZP'1
<br />�� 0. ct.,`1 Apfel Funeral Home, Wood River. Nebraska 68883
<br />(al. (b). AND ICI) i
<br />�I
<br />raw w between •nor ow seam
<br />Yllervel beewasil doom -
<br />PART OTHER CONDITIONS - Corldew.x eonkiboerq to deeM bA not MLWd
<br />a
<br />PART III IF FEMALE. WAS T' IERE A
<br />PREGNANCY N THE PAST 3 MONTHS
<br />VM � NO D
<br />2a. AUTOPSY
<br />($pew �tpl std/
<br />n J U
<br />25. WAS CASE R p�O f�I(`,�
<br />EXAAWER OR / 1
<br />18 1 Yee or Ab1 �/l/Vw
<br />26L ACCIDENT. SUICIDE, HOMICIDE UNDET., 128b. DATE OF INJURY Mb..Oay. Yr!
<br />OR PENDING INESTKGATON iSpw.T,i - -
<br />126c. HOUR OF INJURY
<br />26d. DESCRIBE MOW 04AAW OCCURRED
<br />-
<br />299. 6WRY AT WORK
<br />2nd. PLACE OF INJURY - At home, term, ,YeeL %clay,
<br />26g. LOCATION STREET OR RF D. NO. - CITY OR TOWN STATE
<br />(Spw,fy Yee or Not
<br />once building. etc. (Specify)
<br />st
<br />a
<br />o27d.
<br />ra. DATE OF DEATH 11146., Day. Yr.)
<br />I <-
<br />I g�t
<br />o
<br />26a. DATE SIGNED lMo_ Dry Yr)
<br />26b, TAW OF DEATH
<br />2Il DATE 9KGNED ft, Day. Yr.) `/�� 27c. TIME OF DEATH y/J /�
<br />l I O . f1h7
<br />20m. PRONOUNCED DEAD fAb_ Oily. Yr/
<br />no PRONOUNCED DEAD (AbWr)
<br />To to best of my k IIe 10"
<br />-�
<br />2%. On the bens of ewnwukon ononor mWeepaeorl. In my wwwon dear cacwtod st
<br />Caun(tl Sta%d.
<br />and Ties )I 1'~
<br />$ is
<br />a» erne. M[e ono Nett .. ' r to the Caww slued
<br />Sr^hatlse and TePPI
<br />2fIL DO TOBACCO USE CONTRIBUTE TO T4 DEATH? 30a. HAS ORGAN OR TISSUE
<br />DONATION BEEN CONSIDERED?
<br />30b WAS CONSENT GRANTED1
<br />D YES ❑ NO NO=N D YES
<br />I40
<br />Z YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER JPHYBICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY)
<br />f i vpe ce Pram)
<br />William L. Fowles MD 716 AlRha St Grand
<br />Island, T
<br />32a. REGISTRAR n
<br />32b DATE FILFD BY O.MSTPAP :--- Day Yr,'
<br />f --�� EXHIBIT 11Btt
<br />
|