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<br />
<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 RE-GOilQ.ONFILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/S~.~/!Jjj;_'CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -~:"" ~~~?:':":J~ '~':::'.~,g..c~:\_
<br />
<br />DATE DF ISSUANCE ft~~~ "
<br />
<br />
<br />:~o~~~g1~ 200601254 H~~~~~:~:I~:~
<br />
<br />. --- --,;,"- ~,
<br />. _. ...:. m :.:(.-
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANcE A'ND_EilipPORT 0 6 2 0 ? 8 2
<br />CERTIFICATE OF DEATH-c- .
<br />
<br />...
<br />
<br />\
<br />
<br />
<br />DECEDENT'S.NAME (Flral, Middle, Last, Sulflx) 2. SEX
<br />
<br />_ GpO!'! ThomA-:=: _~_chumacher ,Male "
<br />4. CITY AND STArE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5e AGE.Lasl Blrlhdey rb UNDER 1 YEAR 50. UNDER 1 DAY
<br />(Yrs) 75 MOS. l~ HOURS MINS
<br />Nebraska ~
<br />
<br />7. SOCIAL SECURITY NUMBER -l'aa. PLACE OF DEATH
<br />
<br />5 0 5 - 3 4 - 7 2 1 7 1:I.Q.S.I'lIAl.: iXi Inpatlenl
<br />
<br />FACILITY-NAME (If not institution, give street and number) 0 ER/outpetlent
<br />FRancis Medical Center
<br />_I U ''Ai<
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />anuary 12, 2006
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />April 23, 1930
<br />
<br />QII:IfB;
<br />
<br />o Nursing Home/LTC 0 Hospice Facility
<br />
<br />o Decedenl's Home
<br />
<br />LJ Olilc:;~(Op.;Ail__
<br />
<br />9a. RESIDENCE-STATE
<br />
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />
<br />Ashton Ave.
<br />
<br />lOa. MARITAL STATUS ATTIME OF DEATH I:lMarried 0 Never Married
<br />
<br />J9b~:~1
<br />
<br />LCOU~T: ~ ~EATH
<br />LefTY O~T;W~ n d~-s 1 and
<br />.. 'J ge. AP{ NO- 9~Z~ ~O~\ -~~~~ITY~IM~~
<br />
<br />jOb. NAME OF SPOUSE (First, Middle, Last, Sultlx) If wife, give maiden name.
<br />
<br />80. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Island
<br />
<br />o Married, bul seperaled U Widowed 0 Divorced 0 Un~nown
<br />
<br />Anna Tharnish
<br />
<br />11. FATHER'S.NAME (Firsl,
<br />Otto
<br />
<br />Middle,
<br />Hermann
<br />
<br />Middle, Melden Surname)
<br />Lenora Johnson
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Schumacher
<br />
<br />CC;N~E;O.
<br />
<br />CITY / TOWN
<br />Cemetery, Maxwell,
<br />
<br />Wif~.
<br />160. DATE (Mo., Day, Yr.)
<br />Jan. 17, 2006
<br />
<br />STATE
<br />Nebraska
<br />
<br />18. PART l. Enter the chain nf Avtmt~,,'disea.$esj Injuries, or compllcat!onsnthat directly caused the dea.th. DO NOT enter terminal events such as cardiac arrest,
<br />'eaplralory arrast, or ventricular fibrillation wilhoutahowlng the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addltlonelllnealf necessary.
<br />
<br />IMMEDIATE CAUSE (Flnel
<br />disease or condition resulting
<br />In death)
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />(a)~~/(__.-'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />, onaetto dealh
<br />
<br />~i';/ ~_6- ~" _~~"'.., I'Y_~'~'< .-- ~----
<br />
<br />onoet 10 death
<br />
<br />~
<br />
<br />Sequenllally list condltlona, If
<br />any, le.dlng to the caua.llst.d
<br />on line 8.
<br />EnWth. UNDERLYING CAUSE
<br />(diseaa. or InJury that Initiated
<br />the .vents r.sultlng In de.lh)
<br />lAST
<br />
<br />(b).___ ('1'2,. x;'-10"r'.. <" 'i'(~" /.;;~\:
<br />DUE TO, OR AS A CONSEQUENCE OF: --
<br />
<br />onset to dealh
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onset to death
<br />
<br />(d)
<br />
<br />18 PART II OTHER SIG~I~ANT CO~DiTLONS.C09dltlon"fontrlbullng 10 Ihe dealh \lIJ~~ot resJlltlngAI1 the underlyln(l.g..a.\!se.ll1ven In PART I
<br />r/ic' :9>'" ,/-/tt".7 (J'tt..hf) //c"/i,/ ,/(I".rV-
<br />
<br />---2:~/(~/"" . ;t::t. ~~~/~~~\'~l ,cwrQ..
<br />
<br />20.IF FEMALE: . 21a.M____AA~ ER OF DEATH 21b.IFTRANSPORTATiON INJURY
<br />
<br />o Not pregnant wllhin past year pYNatural 0 Homicide Q Driver/Operator
<br />o Passengar
<br />:~ __~I 0 Pregnanl at lime of dealh 0 AccldenlD Pending Inve,tlgallon
<br />. ~ _1 0 Pedestrian
<br />;::i~} 0 Not pregnant, but pregnanl within 42 days 01 dealh 0 Suicide 0 Could nol be determinad
<br />'I" U~~
<br />;.~ -- :1., U Nol pregnant, but pregnenl43 days to 1 yea' befo,e death COMPLETE CAUS~__ __ OF ATH?
<br />
<br />I'!" :%
<br />~ ~~ 0 un~~own I~~regnanl within ~epasl yaar. 0 YES NO
<br />
<br />
<br />Vr j', 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY.AI home, farm. atreet, factory, office building, construction ,ile, etc. (Specify)
<br />
<br />
<br />
<br />~I?:~ 22"dlNJURY AT WO;J:K? -- - 22a DESCRIBE HOW INJURY OCCU:RED -
<br />
<br />, 0 YES 0 NO
<br />/ 11 ~ -
<br />;&!."'1,1 22f. LOCATION OF INJURY. STREET & NUMBER, APT NO.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OHCORONER CpNT~TED?
<br />l;J YES ul--1'lO
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />U.~/
<br />
<br />DYES
<br />
<br />21 d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />
<br />CITYITOWN
<br />
<br />STArE
<br />
<br />ZIP CODE
<br />
<br />
<br />_ ~ _ .._.'<"l,,")""-"-'~ ..,.,-:;:,"
<br />
<br />.bATE OF DEATH (Mo., Day, Yr.)
<br />Ja~~ary_~?, 2006
<br />
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />
<br />~~~
<br />}l~'"
<br />.!!~~
<br />c.D.. :.:( ::J
<br />~~~~
<br />Jj':l!;.
<br />00
<br />~a:CJ
<br />o ~
<br /><.> 0
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />23d. To Ihe best of my ~nowledge, dealh occurred al Ihe lime, dale and piece
<br />and due to Iha caua,'lalSlaled. (Signature and Tille) "
<br />1/".:":.>" ...~,.,' .,
<br />/..,<~ }..,~
<br />
<br />25'DIDTOBA~?\OUSl!tONTRIBUTETOTHE DE TH7 26a.HAS ORGAN OR TISSUE D?NATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ~.
<br />
<br />o YES NO LJ PROBABLY 0 UNKNOWN 0 YES NO Nol Applicable If 26a Is NO 0 YES. NO
<br />----V:NAMETITL AND AD[lRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR C6UNT~TORNEY) (Type or P~nt) - .~ . .. ....
<br />Jan~ A. McDonald, M.D. 800 Alpha Ave., Grand Island, Nebraska 68803
<br />
<br />24e. On the basis of examination and/or investigation, In my opinion dealh occurred at
<br />the lime, date and piece and due 10 Ihe ceuse(s) staled. (Slgneture and Tille) "
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />AJ1ti{;. ,J.
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />JAN 1 9 2006
<br />
<br />t= '/.. h ; h;f
<br />
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