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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 ORIGINALRECORD ON nLF-1WTtl
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS: SECIVON, MAN *
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />ANLEY S. COOPEff
<br />AUG 2 3 2002 200209527
<br />ASSISTANT- STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMANFTSERIAMEt SYSTEM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND1 SUPPORT
<br />VITAL STATISTICS
<br />CERT[FICATE OF DEATH n i n Q ;,q
<br />I DFCEDENI RANI ' MenaFfT VIDULo >;I
<br />2 sEx - -�ti3 DATE OF DEATH 4!r,—' �.
<br />Wilhelmina Romyn Schultz
<br />gus 14, 2002
<br />Female Au t
<br />CITY AND STATE OF BI9TH Y in D.SA name c0unbv
<br />5a AGE -aM 9rlpeav
<br />UNDER I YEAR
<br />UNDER • BAY
<br />6. DATE OF BIRTH MUUM. Dar e
<br />Lisle, New York
<br />s180
<br />MO$ DAYS
<br />BcHOVas MIN$
<br />January 10, 1922
<br />SOCIAL SECURTIY NUN1FE=
<br />BA 'LACE OF DEATH - - -
<br />557 -14 -1875
<br />H..PITAL © ,Latta" OTHER ❑ NN,Rnq Rome
<br />❑ FR Om0a6enl ❑ gesacnce
<br />Be FACILITY N, mnor...tDOM,, ne Sl2Mr and nu J
<br />Mary Lanning Hospital
<br />'
<br />❑ DOA ❑ D,be/r50e<W
<br />Bc CITY TOWN OR LOCATION OF DEATH
<br />Be INSIDE CITY LIMITS
<br />Be. COUNT Y OF DEATH
<br />Hastings
<br />YaA K] No ❑
<br />Adams
<br />2, RESIDENCE STATE
<br />9pCOUNTY
<br />9c CRY. TOWN OR LOCATION
<br />9p. S I HEET AND NUMBFR6 /JyrJ ig,�p CWel 3 ^WSOE CRV LIMBS
<br />Nebraska
<br />Hall
<br />Wood River
<br />8587 W WoodROi3ver Rd
<br />IO RACE Ieg WFUe. BIaEk Amencw Feian.
<br />11. ANCESTRY Ieq.,taller. Meucen. GKI Al, 12 X] WIDOWED
<br />19 NAME SPOUSE "' -'R grve ma Man rumel
<br />vtk[ite
<br />°� " "' Dutch EVER DIVORCED
<br />Albert Schultz
<br />MANN,
<br />1Je USUAL DCCUPATIUN IGrv¢gryd WJ /XW/IB dNlIl9 mOS1
<br />tAb HIND OF BUSINESS INDUSTRY
<br />_
<br />15 EDUCATION $pemly only 11igbe91glade ce1101elee
<br />Or xpX Ne, d /eMedl
<br />u� Assembler
<br />Electrical Supply
<br />—
<br />HATHIlaHl�ae�nea,y lD 121 elleq¢ 11 IF, ,.I
<br />,MIDDLE
<br />16. FATHER NAME REST MIDDLE LAST i
<br />MOTHER FIRST MAIDEN SLENAME
<br />Peter Romyn
<br />Catharina Wilhelmina Eri
<br />18. WAS DECEASED EVER IN US ARMED FORCES?
<br />19a. INFORMANT. NAME
<br />YeA Wyes grve Y1 aM dale., of sa AcM
<br />NO
<br />Albert A 1
<br />191, INFORMANT MAILING ADDRESS ,STREET Ofl RFD NO CITY OR TOWN STATE ZIP!
<br />8587 W Wood River Rd Wood River, NE 68883
<br />n EMBALMER - SIGNATURE B LICENSE NO
<br />21a. METHOD OF DI$POSDON
<br />21b DATE 21[
<br />CEMETERY OR CREMATORx NAME
<br />❑Bueal
<br />8/18/2002
<br />Central NE Cremation Si
<br />❑R¢mg.al
<br />2 FUN L OME NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STAB.
<br />Ap el Funeral Home
<br />®C,emaliM ❑ Donal
<br />II Gibbon, NE
<br />o,
<br />22p FUNERAL HOME AODRE55 ,STREET OR RED .NO. CITY OR TOWN STATE ZIP, - - --
<br />P.O. Box 126 Wood River, NE 68883
<br />-- —— -
<br />23 IMMEDIATC ISF IENi ONLYONFCAIISE PFR LINEFO ^.gyp \AVID, II Inle�ea pe rvoen on.n ,. ..n
<br />PART I
<br />r _
<br />IaDUE
<br />TO. OR AS AC SEWENCE OF � 1.11.1C.A. onset arc ne -ea
<br />101 ry v SPjji/
<br />DUE TO OR AS A CONDEWLNCE OF - - -
<br />Ic1
<br />OTHCH SGNIFILANT CONDITIONS -Cmd m'11rIbM H, lcE death bulno relaleo PART III IF FEMALE. WAS THERE A 2J AUTOPSY
<br />PART
<br />125. WA$ 4�E REFERRED IL MCD'CAI.
<br />'. PRFf.NANCV M THE PAST 9 MONirvS° -
<br />AMINER OF CORO,�N
<br />it Na
<br />IAgez l]bal veA No Yes.. ❑
<br />Yee Nc
<br />26a
<br />26e DATE OF INJURY IMO OR, Y/J 126, HOUR OFIWURY
<br />--_-__
<br />250. OESPRICE HOW INJURY OCCURRED
<br />n 'roam ❑ undele Once
<br />'
<br />M
<br />❑Swale ❑RV.,F,
<br />MY INJURY AT WORK
<br />261 PLAexcel N
<br />CE OF INJURY -A160 .lam ex lacM,
<br />OCATION STREET OR FU. NO. UUYOR TOWN ST4TL
<br />269 L R
<br />❑ rvomlaee Ioresugauon
<br />res ❑ No ❑
<br />dl omlmne. el, ISpecl
<br />127a DATE OF DEATH (MO. Oav ✓ /.l
<br />_
<br />20a. DAZE SIGNED !MO. Day. v;;
<br />2Bp TIME OF DEATH
<br />il�tloL
<br />N
<br />o =
<br />&`?S
<br />DATE IMO.,
<br />i
<br />Pc. TIME OF DEATH
<br />-
<br />20c vgONOUNCED DEAD IMb Oey Yil
<br />20p. PRONOUNCED OFAD /Ham
<br />12-Ip
<br />133
<br />o'
<br />x
<br />M
<br />�w'
<br />C
<br />B IxTd TOmebesml unowleepe oeaa ee and due to lne
<br />xee- Dnmebasi— sme.ammaila, and o /�n.esayalmn�n my oPmon Beam occe�md aI
<br />cauulsl Male Imo,.'
<br />me uma 1 .I- Lc geed aN Jul m me caysels slat V.
<br />ISM -1u, and TNel1'
<br />ISnaWre and Team
<br />29 OID Tp54CCO USE CONTRIBU TH� EATM?
<br />a HAS ORGAN DR TISSUE CONA -EN LONSIDEPE02 30.p
<br />E❑
<br />_
<br />WAS CONSENT GRANTED'
<br />❑ YES NO ❑ UNKNOWN
<br />ES NO
<br />❑ YES L-�✓
<br />Jl NAMEANDAOOHE$$OFCERTIFIER PHYSICIAN .CORONER 'S PHYSICIAN OR COUNTY ATTORNEY, llyyep PrvM,'
<br />Paul C. Wibbels MD 211P N. KaV§a5 Hastings, NE 68901
<br />Jxa. REGISTRAR
<br />32p DATE FILED BYAUG
<br />�G
<br />2 22002
<br />'r .
<br />
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