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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECQfJQJ)NFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlST/flS'SEMiQf;F,WthcH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS . =-":;;,-.,,--"--:1. =:=;o,.c,.~o. ~'.-. \
<br />
<br />
<br />
<br />DAT~~~S;V~N;;05 20051" 0442 I,~r:;~~~:
<br />
<br />LINCOLN, NEBRASKA \ HE~1.,T~r-~NQ, HUMAN S~VIt:J11S
<br />
<br />-
<br />
<br />.',;
<br />
<br />~
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<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE1\ND$l.,If!,~9E\Tf!'I1::
<br />__ CERTIFICATJ: Of DEATH __ ___. ,._' U..J
<br />
<br />09471
<br />
<br />Middle,
<br />Gene
<br />
<br />LaS!,
<br />Schmidt
<br />
<br />Sulflx)
<br />
<br />2, SEX
<br />Male
<br />
<br />3, DATE OF DEATH (Mo.. Dey, Yr,)
<br />Au .19, 2005
<br />
<br />e, DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />Sa, AGE.LaSI Blrlhday
<br />(Yrs,)
<br />
<br />5b, UNDER 1 YEAR 5c, UNDER 1 DAY
<br />MOS DAYS--HOURSl MINg..-
<br />
<br />
<br />Be, PLACE OF DEATH
<br />
<br />66
<br />
<br />Sept. 16, 1938
<br />
<br />Columbus,
<br />
<br />Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />508-48-3369
<br />
<br />eb, FACILITY-NAME (If nol Inslitullon, glvo slr..1 and number)
<br />
<br />o ER/Outpallonl
<br />
<br />Qlli!;B: 0 Nursing Hom./LTC 0 Hospice Faellily
<br />
<br />b Decedent's Home
<br />
<br />1:f0SPITAL; U Inpalient
<br />
<br />2815 Stagecoach Place
<br />
<br />o CO'\ U Olh.r (Speclly)
<br />
<br />.:--- 18d'II~~flOF DEATH
<br />
<br />90. CITY OR TOWN
<br />Grand Island
<br />
<br />, J;;;' APT. NO _l:~-8C80 1
<br />
<br />
<br />lOb. NAME OF SPOUSE (First, Mlddla, Lasl, Sulflx) II wll., give maiden name.
<br />
<br />9g, INSIDE CITY LIMITS
<br />:fu YES 0 NO
<br />
<br />ec, CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />Grand Island 68801
<br />
<br />9a, RESIDENCE-STATE", _ --I~~iTYl
<br />
<br />
<br />9d, STREET AND NUMBER
<br />
<br />J8l5 Stagecoach Pl~ce_
<br />10'-, MARITAL STATUS AT TIME-OF DEATH X::I Merrled "0 N.ver Merrled
<br />
<br />Jan Schlensker
<br />SUlfIx)"rl2 MOTHER'S.NAME (FlrSI,
<br />Schmidt Anna
<br />-- - -
<br />13. EVER IN U,S, ARMED FORCES? Give dal.s 01 servloell yes. 14a. INFORMANT-NAME
<br />(Yas, no, or unk.) Yes 11 / 5 6 - 11 / 6 2 J an S ch mid t
<br />~ --. -... -.-.
<br />15, METHOD OF DISPOSITION 16e. E~~ER'SIGNAT. .UR) c;:y. '
<br />LXsurlal o Donellon . M~"Y tj,: dj ')c"
<br />o Enlombmenl lad CEMETERY, C~MATORY OR OTHEI?LOCATION
<br />
<br />o Dlvoroed U Unknown
<br />
<br />Middle,
<br />
<br />Last I
<br />
<br />Middle, Meldon Surnam.)
<br />Von Bergen'
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />Louis
<br />
<br />H.
<br />
<br />CITY /TOWN
<br />
<br />, Gc, DATE (Mo" Day, Yr, )
<br />U8.ust 24. 2005
<br />STATE
<br />
<br />1Gb, LICENSE NO.
<br />1328
<br />
<br />Westal""n Memoria,~_ Park
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, Clly or Town, Sial.)
<br />
<br />o Othor (Speolly)
<br />
<br />Grand Island
<br />
<br />PART I. Enlar Ih. chain o!.~~etUa--dlsaas.s, Injuries, or oomplle.tionsnlhat dlreolly oeu.ed Ih. d.ath, DO NOT enler I.rmlnalevenls .uch as cardiao arrest,
<br />r.splralory erre.1. or venlrlcular librlllellon wlthoul showing Ihe ellology. DO NOT ABBREVIATE. Enlor only on. cause on ellne. Add addlllonalllne. II nec.soery.
<br />
<br />IMMEDIATE CAUSE (Final
<br />dIsease Or condition rasurtlng
<br />In dealh)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(aJ jYh: LCV:dt G\,C~A,:
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />on.el 10 dealh
<br />
<br />"]
<br />0:LtV~:.1
<br />
<br />( /t., .. , .(/\ 6>'1""1 t.-
<br />.t-. "L-L.( , VV I I.. '\.
<br />
<br />fYlon'/h()
<br />
<br />onsel to death
<br />
<br />Sequenlially list eondllion.,I! (b)
<br />any,I..dlng to the oeusellsl.d DUE TO, OR AS A CONSEQUENCE OF;
<br />on l1ne 8.
<br />Enter the UNDERLYING CAUSE
<br />(dl..... or Inlmy thet Inltl.,.d (0)
<br />theevenlsreeunlnglnd.ath) DUE TO, OR AS A CONSEQUENCE OF:
<br />lASf
<br />
<br />on.ollo d.alh
<br />
<br />onsel to death
<br />
<br />(d)
<br />
<br />lB, PART II. OTHER SIGNI~tCANT CONDITIONS.Condlllons oontrlbutlng to Ih. d.alh bUI nol reeulllng Inlh. underlying ceusa given In PART I.
<br />
<br />t. hl'tA) n/,> C {I b~.I()' LU;C,\- V.e.CiAA./6'j (l, \.-.<;c{(v:Lf,"
<br />
<br />---;;~FEMAI.E:' ... '21a MANNER OF DEATH' - ;lb-'IF TRANSPC)RTA;ION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />Din Nalural 0 Homlolde U Drlver/Operetor
<br />Nol pre9nant within pasl year f"\
<br />o pr.gnanl at lime 01 dealh 0 AceldenlO pondlng Invosllgellon 0 pesseng.r
<br />o Not pregnanl, bUI pregnant wllhin 42 deys 01 death U Sulcldo 0 Could nol be determlnod 0 Pedestrl.n
<br />o Not pregnant, bul pregnanl43 dey. 10 1 year before deelh 0 Other (Speolty)
<br />o Unknown II pregn.nl wllhln Ihe po.' y.ar
<br />
<br />'9, WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />DYES
<br />
<br />9k NO
<br />
<br />DYES
<br />
<br />~NO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22e. DATE OF INJURY (Mo" Dey, Yr.)
<br />
<br />22b. TIME OF IIIJURY 220. PLACE OF INJURY-AI homo, larm, streel, 'eotory, ollico building, oonslruclion slle, elc. (Sp.cify)
<br />m
<br />
<br />22d, INJURY AT WORK?
<br />
<br />22a, DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO,
<br />
<br />CITY/TOWN
<br />
<br />ST)IJE
<br />
<br />ZIP CODE
<br />
<br />23e, DATE OF DEATH (Mo" Dey, Yr.)
<br />August 19. 2005
<br />
<br />23b, DATE SIGNED (Mo" Day, Yr.)
<br />Au ust 19 2005
<br />
<br />24a. DATE SIGNED (Mo" Day, Vr.)
<br />
<br />24b, TIME OF DEATH
<br />
<br />am
<br />
<br />z,"
<br />!,~\l!
<br />!~~
<br />e.<I.<::;
<br />E"tZ
<br />llffizO
<br />1J~g
<br />~a::O
<br />815
<br />
<br />m
<br />
<br />23c, TIME OF PEATH
<br />10:30
<br />
<br />24c. PRONOUNCED DEAD (Mo" Dey, Yr.)
<br />
<br />24d, TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To the hesl 01 my knowledge, death occurred el Ihellme, dal. and pleoe
<br />d due 10 Ihe oauoe(s) slaled, (Signature and Title) ,.
<br />
<br />} i (1.' ./j"1 nl. .T.,,)
<br />-.' l,L. :./ '../ C,t"t"~0V.l
<br />25, DID TOBACCO USE CONTRIBUTET THE DEATH?
<br />
<br />24e. On the basis of examInation and/or Investigation, 11"1 my opInIon death occurred at
<br />Ihe lime, data and pl.ce .nd du.lo Ihe oeuse(s) slaled, (Slgnalure and Title) ,.
<br />
<br />26a, HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />2Gb, WAS CONSENT GRANTED?
<br />Nol A~~lIeeble if 26elo, ~O U YES Sl NO
<br />
<br />.2lt YES 0 NO 0 PROBABLY .0 UNKNOWN 0 YES .' lQ NO
<br />--27 NAME, TITLE AND ADDRESS OF CERTIFIER (Pi'WSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) Tfype or Print) -,-
<br />
<br />Anita Desh ande M.D. 2116 W. F~idle
<br />
<br />
<br />J&.
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />.Grand I~land~ NE 6880
<br />
<br />28b,-DATE FILED BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />AUG 26 2005
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