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t
<br />izt
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<br />WHEN TIES COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALM AND)ANf1�41fEtSERWCES
<br />SYSTEK IT CERTFES TFE BELOW TO BE A TRUE COPY OF THE _ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL , IS
<br />THE LEGAL DEPOS/TORY FOR WTAL RECORDS -`- =- =-
<br />D SSUANCE 200411432 - -"`'
<br />1 1 2 1997 - ED9iPER
<br />A ReMITM, R
<br />UNCOLN, NEBRASKA HEALTH AID!F 89RRCESSftItM
<br />I STATE OF NEBRASKA - DEPARTMENTS F!EAvTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />C tD
<br />N
<br />C--)
<br />CD
<br />s�
<br />En
<br />F-► 8
<br />-� CD
<br />W �
<br />N Z
<br />O
<br />1. DECEDENT -NAME FIRST MIDDLE UST
<br />2. SEX
<br />3. DATE OF DEATH /Month Day. Year!
<br />n
<br />Female
<br />I July 29, 1997
<br />a
<br />7O
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />-- -
<br />O -a
<br />5c. HOURS' MINs.
<br />(Yrs.l 5b.
<br />Primrose, Nebraska
<br />65
<br />M
<br />Aril 7 1932
<br />7. SOCIAL SECURTIY NUMBER
<br />Be . PLACE OF DEATH
<br />505 -36 -8451
<br />=
<br />8b. FACILITY - Name /Mnat ureliN90r4 give abeet and number)
<br />_Bryan nemorial Hospital
<br />0
<br />Bc. CITY TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Lincoln
<br />Yes �] No ❑
<br />I Lancaster
<br />ga. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER ttncluding Zrp�gQeJv
<br />1
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />0
<br />1518 E. Capital Avj�e.
<br />Yes ® No ❑
<br />10. RACE - (e.g., While. Black. American Indian,
<br />11. ANCESTRY Ie.g.. Italian. Mexican. German. elc1 10
<br />12. ® MARRIED ❑WIDOWED
<br />13. N tN wile give maiden name)
<br />ed.l peaty,
<br />ite
<br />IsPecdyl
<br />American
<br />3
<br />r �
<br />14a. USUAL OCCUPATION /Give kindol work dare d&*V most 14b.
<br />KIND OF BUSINESS INDUSTRY I
<br />15. EDUCATION ISpecity only highest grade completed)
<br />WHEN TIES COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALM AND)ANf1�41fEtSERWCES
<br />SYSTEK IT CERTFES TFE BELOW TO BE A TRUE COPY OF THE _ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL , IS
<br />THE LEGAL DEPOS/TORY FOR WTAL RECORDS -`- =- =-
<br />D SSUANCE 200411432 - -"`'
<br />1 1 2 1997 - ED9iPER
<br />A ReMITM, R
<br />UNCOLN, NEBRASKA HEALTH AID!F 89RRCESSftItM
<br />I STATE OF NEBRASKA - DEPARTMENTS F!EAvTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />C tD
<br />N
<br />C--)
<br />CD
<br />s�
<br />En
<br />F-► 8
<br />-� CD
<br />W �
<br />N Z
<br />O
<br />1. DECEDENT -NAME FIRST MIDDLE UST
<br />2. SEX
<br />3. DATE OF DEATH /Month Day. Year!
<br />Delores Marie Schade
<br />Female
<br />I July 29, 1997
<br />a
<br />C5 Cfl
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />-- -
<br />O -a
<br />5c. HOURS' MINs.
<br />(Yrs.l 5b.
<br />Primrose, Nebraska
<br />65
<br />Aril 7 1932
<br />7. SOCIAL SECURTIY NUMBER
<br />Be . PLACE OF DEATH
<br />505 -36 -8451
<br />HOSPITAL: ® Inpabsto OTHER ❑ Nursing Home
<br />❑ ER OulpOW ❑ Residence
<br />8b. FACILITY - Name /Mnat ureliN90r4 give abeet and number)
<br />_Bryan nemorial Hospital
<br />0
<br />Bc. CITY TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Lincoln
<br />Yes �] No ❑
<br />I Lancaster
<br />ga. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER ttncluding Zrp�gQeJv
<br />1
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />0
<br />1518 E. Capital Avj�e.
<br />Yes ® No ❑
<br />10. RACE - (e.g., While. Black. American Indian,
<br />11. ANCESTRY Ie.g.. Italian. Mexican. German. elc1 10
<br />12. ® MARRIED ❑WIDOWED
<br />13. N tN wile give maiden name)
<br />ed.l peaty,
<br />ite
<br />IsPecdyl
<br />American
<br />3
<br />r �
<br />14a. USUAL OCCUPATION /Give kindol work dare d&*V most 14b.
<br />KIND OF BUSINESS INDUSTRY I
<br />15. EDUCATION ISpecity only highest grade completed)
<br />of waking life, even If refkedl �)
<br />Elementary or Secondary 10 -121 College It .4 or 5.1
<br />6-°
<br />Cf)
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST 17.
<br />N
<br />�
<br />Mary Vanark
<br />1B WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />1ga. INFORMANT - NAME
<br />)Yes . no. a unk.) IN yes. give war and dates of servicesl
<br />ITracyStinson
<br />No
<br />N
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />9431 Avon Lane Lincoln, Nebraska 68505
<br />20 EMBALMER - SIGNATURE 6 LICE E NO
<br />W
<br />rn
<br />CEMETERY OR CREMATORY NAME
<br />-Cecw- /2
<br />❑Burial ❑ Removal
<br />r�
<br />WHEN TIES COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALM AND)ANf1�41fEtSERWCES
<br />SYSTEK IT CERTFES TFE BELOW TO BE A TRUE COPY OF THE _ WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL , IS
<br />THE LEGAL DEPOS/TORY FOR WTAL RECORDS -`- =- =-
<br />D SSUANCE 200411432 - -"`'
<br />1 1 2 1997 - ED9iPER
<br />A ReMITM, R
<br />UNCOLN, NEBRASKA HEALTH AID!F 89RRCESSftItM
<br />I STATE OF NEBRASKA - DEPARTMENTS F!EAvTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />C tD
<br />N
<br />C--)
<br />CD
<br />s�
<br />En
<br />F-► 8
<br />-� CD
<br />W �
<br />N Z
<br />O
<br />1. DECEDENT -NAME FIRST MIDDLE UST
<br />2. SEX
<br />3. DATE OF DEATH /Month Day. Year!
<br />Delores Marie Schade
<br />Female
<br />I July 29, 1997
<br />4, CITY AND STATE OF BIRTH (d not it U.S.A. name counbyl
<br />5a. AGE -Last SiMday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />6. DATE OF BIRTH tMondl. Day. YBNI
<br />MOS. DAYS
<br />5c. HOURS' MINs.
<br />(Yrs.l 5b.
<br />Primrose, Nebraska
<br />65
<br />Aril 7 1932
<br />7. SOCIAL SECURTIY NUMBER
<br />Be . PLACE OF DEATH
<br />505 -36 -8451
<br />HOSPITAL: ® Inpabsto OTHER ❑ Nursing Home
<br />❑ ER OulpOW ❑ Residence
<br />8b. FACILITY - Name /Mnat ureliN90r4 give abeet and number)
<br />_Bryan nemorial Hospital
<br />❑ D" ° - - -- - -.__ n__ �= _` -_ -.. - --
<br />Bc. CITY TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Lincoln
<br />Yes �] No ❑
<br />I Lancaster
<br />ga. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER ttncluding Zrp�gQeJv
<br />1
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />0
<br />1518 E. Capital Avj�e.
<br />Yes ® No ❑
<br />10. RACE - (e.g., While. Black. American Indian,
<br />11. ANCESTRY Ie.g.. Italian. Mexican. German. elc1 10
<br />12. ® MARRIED ❑WIDOWED
<br />13. N tN wile give maiden name)
<br />ed.l peaty,
<br />ite
<br />IsPecdyl
<br />American
<br />NEVER DIVORCED
<br />,
<br />Ardene Schade
<br />14a. USUAL OCCUPATION /Give kindol work dare d&*V most 14b.
<br />KIND OF BUSINESS INDUSTRY I
<br />15. EDUCATION ISpecity only highest grade completed)
<br />of waking life, even If refkedl �)
<br />Elementary or Secondary 10 -121 College It .4 or 5.1
<br />Homemaker
<br />Own Home
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Charles Molcz k
<br />Mary Vanark
<br />1B WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />1ga. INFORMANT - NAME
<br />)Yes . no. a unk.) IN yes. give war and dates of servicesl
<br />ITracyStinson
<br />No
<br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />9431 Avon Lane Lincoln, Nebraska 68505
<br />20 EMBALMER - SIGNATURE 6 LICE E NO
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21c
<br />CEMETERY OR CREMATORY NAME
<br />-Cecw- /2
<br />❑Burial ❑ Removal
<br />Au ust 2 199
<br />Westlawn Memorial Park
<br />22a FUNERAL HOME -NAME
<br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Livin ston- Sondermann F. H.
<br />❑Cremation ❑Donaim
<br />Grand Island Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />Rd. Grand Island, Nebraska 68803 -4050
<br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal- Ibl. AND fc1) interval between onset and deal,
<br />PART a /���.a.�-
<br />1 la) / c,�,�'t,2 /Vd IV - L tlr►. h O le 1-k k m ;A
<br />DUE TO, OR AS A CONSEOUENCE OF Interval between onset and deal,
<br />(b)
<br />DUE TO. OR AS A CONSEOUENCE OF Interval between onset and death
<br />(cl
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contdbueng to the death but not related P ART
<br />III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25, WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY
<br />11
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'
<br />(Ages
<br />10 -541 Yes No
<br />Vey n No
<br />Vey NO
<br />26a.
<br />26b. DATE OF INJURY /Ale.. Day. Yr.)
<br />HOUR OF INJURY
<br />26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident F1 Undetermined
<br />r
<br />M
<br />n Suicide ❑ Pending
<br />26e. INJURY AT WORK
<br />26t. PtpCE QF, INJURY - At tnorrne, farm. street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />1 F1 Hom¢ide investigation
<br />Yes No
<br />❑ ❑
<br />office butdlrg, etc tSpecMI
<br />27a. DATE OF DEATH (W. Day. Yr.)
<br />28a DATE SIGNED (Mo.. Day. Yr)
<br />28b TIME OF DEATH
<br />biz
<br />M
<br />a g >
<br />27b. DATE SIGNED (MO.. Day Yrl
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (Mo. Day. Ycl
<br />28d. PRONOUNCED DEAD (Hour!
<br />m
<br />M
<br />¢ s
<br />M
<br />g
<br />o
<br />70. To the best of my k^,�/,�9,,,,���-a��T, death occurred atone fine and place and due to the
<br />2. On the basis d examination andior investigation, in my opinion death occurred at
<br />causelsl stated.`- % - w w
<br />V V
<br />u 0
<br />Nne time. date and place and due to 1ne cause(s) stated.
<br />SI nature and Title IV•`
<br />tae and TiBe
<br />29 010 T CCO USE CONTRIBUTE TO THE DEATH? 30a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />❑ YES NO ❑ UNKNOWN
<br />❑ VIES /
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type or Prinrl
<br />Alan R. Berg, M.D. 2611, Sou 0 h, Lincoln, Nebraska 68506
<br />32a. REGISTRAR
<br />, A i -&A
<br />32b. DATE FILED BY REGISTRAR A40 Day. 1,J00
<br />AU 1997
<br />Real Estate Description: The Southerly Half (S 1/2) of Lots Three (3) and Four (4) in Block
<br />Nineteen (19) in the Original Town, now city of Grand Island, Hall County, Nebraska
<br />W
<br />
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