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<br />STATE OF NEBRASKA
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<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 RECQflDfMH"I..E WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATlSTlCS~CTlQN.cWHlf;H IS
<br />
<br />::~:~::~::ORY FOR YTrAL RECOROS. ~~~~~,
<br />L1NCO~~~E~R~S~~05 2 0 0 6 0 0 9 4 4 H~~~~1~ S;:::Z~<::~~~~.
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<br />STATE OF NEBRASKA - DE. PARTMENT OF HEALTH A. ...NO HUMAN SERVICES FINANCE ANOSUP'POOT." . c:-,:- - .:"'" 1 8 7 9
<br />. -- CERTIFICAT:EOF DEATH .,,,_. "-05 0 J _ _ _
<br />
<br />DECEDENT'S.NAME (Flrsl, Middle, Lest. Sulfix) 2. SEX 3. DATE OF DEATH (Mo.. Day. Yr.)
<br />H!'l-!j ol~ie Caroline Schlotfeldt Female February 14, 2005
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH -[~'. . (AYGrsE..)L....stsBsirtM.y 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (MO'.:-;;-~~
<br />Fox Valley, Saskatchewan. Canada L MOS. DAYS .~I~~.S- May 2S. 1919
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<br />7. SOCIAL SECURITY NUMBER
<br />
<br />s67-12-03;3J
<br />fA,qL~IJx:.~,A.M-'~. If Il~t In~HIU!1
<br />
<br />6.. PLACE OF DEATH
<br />HQ.&E.1.IAk:
<br />
<br />~ Inpoti'n!
<br />
<br />QTI:JEB; 0 Nursing Homo/LTC U Hosplc. F.olllly
<br />
<br />Iv!;' !\fr
<br />
<br />11 ., I' r: ~" r \
<br />
<br />St. Francis Medical Center
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<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand 'Island 68803
<br />
<br />o lXl'\ 0 Other (SpecilyL._
<br />....-~---18d. COUN~Y:~~EATH
<br />
<br />9a. RESIDENCE.STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />118 S. Ingalls St.
<br />
<br />9b. COUNTY
<br />
<br />Hall
<br />
<br />Island
<br />
<br />ge. APT. N~._J9f. ZIP~~~~"~"'.~
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<br />10b. NAME OF SPOUSE (First, Middle, Lest, Sulfix) If wito, glvo maiden nome.
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />J:U YES 0 NO
<br />
<br />10.. MARITAL STATUS AT TIME OF DEATH 0 M.rried 0 Never Merried
<br />
<br />o Marriod, but s.parated Ql Widowed 0 Divorced 0 Unknown
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<br />11. FATHER'S.NAME (First.
<br />Oliver
<br />
<br />Middle,
<br />
<br />Last,
<br />Bolin
<br />
<br />SUlfi'l
<br />
<br />12. MOTHER'S-NAME (First,
<br />Hazel
<br />
<br />Middlo,
<br />
<br />M.lde" Surn.me)
<br />Carr
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<br />13. EVER IN U.S~ ARMED FORCES7 Give d.te, of service if yos. t4a.INFORMANT.NAME
<br />
<br />
<br />~:~~:,::~.~n:: DI~~:::~' !'"' ~i7.I.'.L/Ul Schlotfeld~. "/'1 V 0
<br />
<br />o Cremallon 0 Entombmont 16d' EMETERY. CRE~; O~;~'LOC-ATlON--- CITY / TOWN
<br />OR.moy.1 o Other (Specify) Grand Island Cemetery Grand Island
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slroot, City or Town, St.le)
<br />Apfel Funeral Home, 112? West Second, Grand Island. Nebraska
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<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
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<br />18c. DATE (MD.. D.y, Yr. )
<br />
<br />Febr~~~Y-l7 2005
<br />STATE
<br />
<br />Nebraska
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<br />PART I. Enler Ihe c.ba1!l..9~..diseBs8Sr InJuries, or compllcaUonsnthal dlreclly caused the death. DO NOT enter terminal events such as ca.rdlac arrest.
<br />respiralory arro,l, or vontricular flbrlll.tion without ahowing th. eliology. DO NOT ABBREVIATE. Enter only one cause on . line. Add .ddllionalllnes if necess.ry.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />in death)
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<br />IMMEDIATE CAUSE:
<br />(al ~ 1 Cl i -e,..afJ P o;,-€ LA VIA CJ vu. \ tA-
<br />
<br />ons8110 death
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<br />S' cQ c.P..Lt 'S
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<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />I onset to de.th
<br />I
<br />I
<br />I
<br />I onsel to death
<br />I
<br />I
<br />L.
<br />I onset 10 dealh
<br />I
<br />I
<br />
<br />Sequenti.lly lis! conditions, if
<br />any, leading to the cause listed
<br />on linea.
<br />Enterthe UNDERLYING CAUSE
<br />(disease or Injury that inltlated
<br />the events resulting In death)
<br />LAST
<br />
<br />(b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(0)
<br />DUE TO. OR AS A CONSEOUENCE OF:
<br />
<br />(d)
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<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contrlbuling to Ihe de'lh but not ..sulling in the underlying cau,e given in PART I. I
<br />
<br />Wr. fo~J OL/l C ~ ([J vJc..) ~ I"ctO .:tJ\.svt -tf!'cA@/.-lc.l1-.
<br />"V\.- ~f1 eel Q?'h.v-e...- ~ ~J PO'I IUM
<br />
<br />
<br />t 9. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES ~ NO
<br />
<br />I. oude,
<br />__ 61.. Z_)ct?_
<br />20. IF FEMALE: 21a. MANNER OF DEATH
<br />"f! NOI pregnant wilhin past year 1S( Natural 0 Homicide
<br />o Pregnanj at limo ot death 0 AccidentO Pending Inve'tigallon
<br />o Not pregnant, bUI pregn.nt within 42 days of dealh 0 Suicide 0 Could not be det~rmlned 0 Podostrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />o Not pregn.nl, bUI pregnant 43 days to 1 year betore death 0 Othor (Speclly) COMPLETE CAUSE OF DEATH?
<br />o Unknown il pregnanl within the paS! year 0 YES 0 NO
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<br />::;;:~::'"'r~:::~J::"=~::;,,:i='{" ,"""",,",~.i'~:~~'~:':'d,"' OO""~;OO~'''I'''''~_~~
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<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYIlOWN STATE ZIP COD~ -I
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<br />21b.IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />o Drlver/Op.retor
<br />
<br />o P..senger
<br />
<br />DYES
<br />
<br />~NO
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />
<br />Fc\orua
<br />
<br />23b. DATE SIGNED (Mo.. Day, r.)
<br />;< - liP -05'
<br />
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<br />24a. DATE SIGNED (MD.. Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />Am
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<br />,.,::i:~
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<br />]l>-2
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<br />E">-Z
<br />8ffi!z0
<br />~z:;'
<br />""00
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<br />O~
<br />uo
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<br />240. PRONOUIGED DEAD (Mo.. Doy, Yr.) 24d. TIM" PRONOUNCED DEAD
<br />m
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<br />23d. To the baS! of my knowlodge, doath occurrod at the lime, date and place
<br />and due to the ceLlse(s) Slated. (Slgnel",e and Tille) T
<br />
<br />Ir~ mfJ
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<br />24e. On Ihe b ~ds of examination and/or investigation. in my opinion death occurred at
<br />thetime,.le and place and duo to tho causo(,) ,tatod. (Signature and Tille) T
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<br />26.. HAS ORGAN OR TISSUE DONATiON BEEN CO~"IDERED?
<br />
<br />)QYES 0 NO 0 PROBABLY 0 UNKNOWN 0 YES ):ijNO
<br />V:-NAME:i-ITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo ~';-F";,nt)
<br />Richard Fruehling M.D. 2116 W. Faidley Ave., Grand
<br />
<br />26b. WAS CONSENT GRANTED?
<br />Not Applic.ble If 26. i. NO 0 YES ~__.m.
<br />
<br />Island, NE
<br />
<br />68803
<br />
<br />28.. REGISTRAR'S SIGNATURE
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<br />
<br />28b. DATE FILED BY REGISTRAR (Mo.. D.y, Yr.)
<br />
<br />~l ;
<br />J\ /
<br />
<br />fER 2 :i 2005
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