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<br />HOSPITAL. Inpatient OTHER ® sm
<br />Nurq Home
<br />506 -46 -2378 — — --
<br />9b FACILITY Name /lf not mslirulion, give steer and number) ❑ ER Outpatient ❑ Residence
<br />Lakeview Health & Rehabilitai nr °OA Omer ,Spec,
<br />8c CITY TOWN OR LOCATION OF DEATH 18d INSIDE CITY LIMITS Be COUNTY OF DEATH - - --
<br />Gran' Yes t7 �t Nn I I T41a 1
<br />9a RESIDENCE - STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER llncludlng Zp coder 9e INSIDE CITY LIMITS
<br />Nebraska Hall Cairo 408 S. Said 68824 Yea® No
<br />10 RACE - (eg., Whne Black American Indian. 1 11. ANCESTRY Ie g. Italian. Mexican, German, etcl 12 ❑ MARRIED WIDOWED 13 NAME OF SPOUSE ill wife give maiden name)
<br />etc .I ISceafyl ISpec'y NEVER
<br />White German DIVORCED
<br />M
<br />14a USUAL OCCUPATION Give kind of work done during most 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specdy only highest grade completed)
<br />of work�nq nre. even ✓ renredi Elern.rrl y pr Secondary !0 12) College 11.4 or S -�
<br />Coordinator Senior Citizen Cente 12
<br />16 FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Charles _ _ Kemptar 1 El ha Hod son
<br />18 WAS DECEASED EVER IN US ARMED FORCES? 19a INFORMANT NAME
<br />'Yes - J unk I 1 fit yes y +e war and dates of servlcesl
<br />no___', I— Sherry Kissler
<br />9t) �NF.DRA ANT MAILING AODH_,nS ;S1 REET OR R F D NO.. CITY CH 'OWN STATE ZIP( — - - - - -- - - - -- - --
<br />P.O. Box 73, Cairo, Nebraska 68824
<br />20 EMBALMER - SIGNAT RE 8 LICENSE NO 1 21 a. METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME
<br />7�J Burial Removal JUlY 2 0 2 0 0 C. N. C. S.
<br />?21 FVNVAL HOME - NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funera Home ®Cremation ❑Donator Gibbon Nebraska
<br />22b FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) --
<br />411 West 11th, Wood River, Nebraska 68883
<br />23 IMMEDI TE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. lot AND Icll Interval between onset and seam
<br />PART l
<br />��V�li\�JWy 4�YVP�� ZV Q���Q C�V� -7i,rmeCli,n
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and deal,
<br />fb) C Yyry\ :- ( e,�-� -� y :�; IS c,L-� ✓KL �� �e a-�i
<br />DUE TO OR AS A CONSEQUENCE OF Interval oehveen onset and deal
<br />I _
<br />HE SI (FICA T NDITION - CondI ns contribu ng to the death ut riot rela d PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3MONTHS7 EXAMINER OR CORONER'
<br />(Ages 10 -54) Yes NO Yes No Yes NO
<br />?6a 26b ATE OF INJURY !MO Day. Yrl 26C HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accede rl IJ !Jndeterrr neC M
<br />..rf %.,rnna.
<br />❑ o ice b� (ding. etc iSpeciy/
<br />� mic,de mvesngaUn^ Yes No �
<br />2 a DATE OF DEATH ^l1Mn Dav Yr) 28a DATE SIGNED IMO. Day Yr) 28b TIME OF DEATH
<br />M
<br />27b DATE SIGNED IMO Day Yr 1 1 27C TIME OF DEATH $ > 28c PRONOUNCED DEAD /MO.. Day. YrJ 28d. PRONOUNCED DEAD /Howl
<br />_ M
<br />r ,�TO 1he best of my ynowledge. dealt occurred at the time date an dace and due to me g ° 8 280 On the basis of ecamination and -or mesugatrpn, n my opr,on deal, occurred at
<br />caus0lsi staled. me time, dale and place and due 10 the causelsl stated.
<br />_ I S,gnature and Title/ ► , _
<br />29 DID TOBACCO USE CONTRIBUTE DEAT "H7 `�-- IS. nature and Title ►
<br />30 a HAS ORGAN OR TISSRIE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED'
<br />❑ YES NO ❑ UNKNOWN ❑ YES ® NO ❑ YES ® NO
<br />3 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY( iTVpe or Print)
<br />Steven L. Husen M.D. 2116 aid/ v G.I. NE E
<br />32a REGISTRAR 32b. DATE FILED BY REGISTRAR /MO. Day. Yr./
<br />"+,A x ti►, J1 1L 24,
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<br />WHEN TM COPYCARRIES TIE RAISED SEAL OF THE NEBRASKA HEALTH -AA0 HUMA- &WR" CES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RE4P ft pKF11kAWrH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST�'U.
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS -_
<br />DATE OF ISSUANCE 200311995
<br />AUG 22000 200009499 ASS/ T�
<br />LINCOLN, NEBRASKA HEALTH AND HE�I7[IV,SEIYTEN,
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SECJttt# $,'LRT
<br />VITAL STATISTICS
<br />- ------------------ CERTIFICATE OF DEATH ...__.
<br />- - - - -- - - - -- -
<br />^ES.EDF.N'r NAME FIRST MIDDLE LAST 2 SjEX
<br />3 DATE OF DEATH x014 -m, 0.av Yean
<br />- - --
<br />Opal Irene _Schuett
<br />Fmale
<br />Jul 161
<br />2000
<br />a C17v AND STATE: OF 61R ?H cN not in D S.A. name county:
<br />5a. AGE Last Bldhday
<br />UNDER 1 YEAR
<br />DER t DAY
<br />6. DATE OF BIRTH ;MOWN
<br />Day. Year)
<br />_ Cairo, Nebraska _
<br />(Yrs,
<br />87
<br />51 MOS DAYS
<br />5c RS MI NS
<br />Februar
<br />20
<br />1913
<br />SOCIAL SECURTIY NUMBER I 8a PLACE OF DEATH
<br />- -"
<br />a
<br />HOSPITAL. Inpatient OTHER ® sm
<br />Nurq Home
<br />506 -46 -2378 — — --
<br />9b FACILITY Name /lf not mslirulion, give steer and number) ❑ ER Outpatient ❑ Residence
<br />Lakeview Health & Rehabilitai nr °OA Omer ,Spec,
<br />8c CITY TOWN OR LOCATION OF DEATH 18d INSIDE CITY LIMITS Be COUNTY OF DEATH - - --
<br />Gran' Yes t7 �t Nn I I T41a 1
<br />9a RESIDENCE - STATE 9b COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER llncludlng Zp coder 9e INSIDE CITY LIMITS
<br />Nebraska Hall Cairo 408 S. Said 68824 Yea® No
<br />10 RACE - (eg., Whne Black American Indian. 1 11. ANCESTRY Ie g. Italian. Mexican, German, etcl 12 ❑ MARRIED WIDOWED 13 NAME OF SPOUSE ill wife give maiden name)
<br />etc .I ISceafyl ISpec'y NEVER
<br />White German DIVORCED
<br />M
<br />14a USUAL OCCUPATION Give kind of work done during most 14b KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specdy only highest grade completed)
<br />of work�nq nre. even ✓ renredi Elern.rrl y pr Secondary !0 12) College 11.4 or S -�
<br />Coordinator Senior Citizen Cente 12
<br />16 FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Charles _ _ Kemptar 1 El ha Hod son
<br />18 WAS DECEASED EVER IN US ARMED FORCES? 19a INFORMANT NAME
<br />'Yes - J unk I 1 fit yes y +e war and dates of servlcesl
<br />no___', I— Sherry Kissler
<br />9t) �NF.DRA ANT MAILING AODH_,nS ;S1 REET OR R F D NO.. CITY CH 'OWN STATE ZIP( — - - - - -- - - - -- - --
<br />P.O. Box 73, Cairo, Nebraska 68824
<br />20 EMBALMER - SIGNAT RE 8 LICENSE NO 1 21 a. METHOD OF DISPOSITION 21b. DATE 21c CEMETERY OR CREMATORY NAME
<br />7�J Burial Removal JUlY 2 0 2 0 0 C. N. C. S.
<br />?21 FVNVAL HOME - NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funera Home ®Cremation ❑Donator Gibbon Nebraska
<br />22b FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) --
<br />411 West 11th, Wood River, Nebraska 68883
<br />23 IMMEDI TE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. lot AND Icll Interval between onset and seam
<br />PART l
<br />��V�li\�JWy 4�YVP�� ZV Q���Q C�V� -7i,rmeCli,n
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and deal,
<br />fb) C Yyry\ :- ( e,�-� -� y :�; IS c,L-� ✓KL �� �e a-�i
<br />DUE TO OR AS A CONSEQUENCE OF Interval oehveen onset and deal
<br />I _
<br />HE SI (FICA T NDITION - CondI ns contribu ng to the death ut riot rela d PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL
<br />PART PREGNANCY IN THE PAST 3MONTHS7 EXAMINER OR CORONER'
<br />(Ages 10 -54) Yes NO Yes No Yes NO
<br />?6a 26b ATE OF INJURY !MO Day. Yrl 26C HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accede rl IJ !Jndeterrr neC M
<br />..rf %.,rnna.
<br />❑ o ice b� (ding. etc iSpeciy/
<br />� mic,de mvesngaUn^ Yes No �
<br />2 a DATE OF DEATH ^l1Mn Dav Yr) 28a DATE SIGNED IMO. Day Yr) 28b TIME OF DEATH
<br />M
<br />27b DATE SIGNED IMO Day Yr 1 1 27C TIME OF DEATH $ > 28c PRONOUNCED DEAD /MO.. Day. YrJ 28d. PRONOUNCED DEAD /Howl
<br />_ M
<br />r ,�TO 1he best of my ynowledge. dealt occurred at the time date an dace and due to me g ° 8 280 On the basis of ecamination and -or mesugatrpn, n my opr,on deal, occurred at
<br />caus0lsi staled. me time, dale and place and due 10 the causelsl stated.
<br />_ I S,gnature and Title/ ► , _
<br />29 DID TOBACCO USE CONTRIBUTE DEAT "H7 `�-- IS. nature and Title ►
<br />30 a HAS ORGAN OR TISSRIE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED'
<br />❑ YES NO ❑ UNKNOWN ❑ YES ® NO ❑ YES ® NO
<br />3 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY( iTVpe or Print)
<br />Steven L. Husen M.D. 2116 aid/ v G.I. NE E
<br />32a REGISTRAR 32b. DATE FILED BY REGISTRAR /MO. Day. Yr./
<br />"+,A x ti►, J1 1L 24,
<br />
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