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<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CAHRIE5 THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN-=s,,~RVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RE.~QflfJ~1!oJl(ITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTI~-Sgcrli'N,'WHJfHJ:;
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~!:i'~:..:-:--.'~'-."J.-..-'...-.)r.~~.- ':h~' _......'.
<br />
<br />DATE OF ISSUANCE ",:.,-- 1/.-':.. ~",
<br />APR 0 7 2006' ~ '. TAN.LEYS.'-!;OOPER
<br />ASSISTANt_ STATE REGISTF!AR
<br />LINCOLN, NEBRASKA 2 0 0 6 0 3 2 8 4 HEALTHANo-'HUMAN SERViCES'
<br />
<br />p
<br />
<br />S,".AT..E OF NEBRASK..A - DEPARTMENT OF HEA... LTH AND HUM.A N SERVICES FINAN. ..C...E A. NO SUPAO...W
<br />_ , C~RTIFIC_~TE OF DI;ATH .._~Q
<br />
<br />1. DECEDENT'S-NAME (Flrsl, Middle, Lasl, SUffi') 2. SEX 3. DATE OF DEATH (Mo" Day, Yr,)
<br />______ _._~~lp"h Joh~ Schlal?an_ Male ~an_1!.ary 1 '. 20..2_~
<br />
<br />4 CITY AND SlATE OR TERRITORY, OR FOREIGN COUNTRY OF SIRTH~a AGE-Lasl Brrlhday 5b, UNDER 1 YEAR 50, UNDER 1 DAY 6, DATE OF SIRTH (Mo" Day, Yr.)
<br />(Yrs) MOS. DAYS HOURS MINS, 1910
<br />Ruskin, Nebraska 95 December 22,
<br />
<br />7S0CIALSECURITYNUMBER -_ __ J ::"_T:IDEATH
<br />506-09-5009 0 Inpatient OM8: 0 Nursing Hom.llTC OHospiceFaolllly
<br />.1-.
<br />bU, fAGiUTY.NAM" III nOI Inslilulion, give Slreel and number) 0 ERIOulpalienl XI Docodenl's Home
<br />
<br />Home: 1503 W. Stolley Park Rd.
<br />o M OOlher(Sp.cily)___....__
<br />.--'-"-.,---
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code) -rSdCOUNTY OF DEATH
<br />Grand Island 68803 ~ Hall
<br />
<br />9aR~:~::S~A~Ea-- 19bCOUNTYHal~-- 19CCIT;~R~~W: ISla~-~ .-
<br />9dS~R;E~;ND;~_~E;tol~e~ pa~~ -~'d.. -__________ Jge'APT'~0 9f~;;~~ .... -=r;~~~:CITY~IM~;__
<br />
<br />lOa. MARITAL STATUS AT TIM~ OF DEATH 0 Married 0 Nevor Married lOb, NAME OF SPOUSE (Firsl, Middle, Lasl, Suflix) If wlfo, give maiden name.
<br />
<br />2 0 lilL
<br />
<br />
<br />o Marriod, bul separated 9{ Widowed 0 Divorced 0 Unknown
<br />
<br />Middle,
<br />
<br />Last,
<br />Schlaman
<br />
<br />SUffl')
<br />
<br />12. MOTHER'S-NAME (First,
<br />Doretta
<br />
<br />Middle,
<br />
<br />Maiden Surname)
<br />Ahrens
<br />
<br />13. EVER IN U.S. ARMED FORCES? Givo dales 01 service if yes, 14a.INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yes,no,orunk.) No Richard Schlaman Son
<br />
<br />15. METHOD OF DISPOSITION r6a. EMSALMER-SIGNATU~.. ' . 16b. LICENSE NO. -;'6C DAT~ (M~::D~y, Yr. )
<br />lXBurial UDonallon A~ --.lt~./. "/3.<.5.... January 11, 2006
<br />
<br />o ,.~"'" u '"".,.., '"" "''''",. '""'''''' '" L. -CATION CITY I TOWN STATE
<br />
<br />o Removal UOlher(Specily) Westlawn Memorial Park Cemetery Grand Island, NE.
<br />
<br />- ...----- ._~.,- .---.'.','.---
<br />17e. FUNERAL HOM~ NAME AND MAILING ADDRESS (Strool, City or Town, Slalo)
<br />Apfel Funeral Horne, 1123 West Second,
<br />
<br />PART r. Enter the chaIn of 9venli;--diseasBs, InJurIes, or oomplicalions.-that dIrectly caused the death. DO NOT enter termInal evenls such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation wIthout showIng the etiology. DO NOT ABBREVIATE. Enter only one causo on a line, Add addlllonallinas jf necessary.
<br />
<br />I
<br />I
<br />
<br />I on88110 death
<br />I
<br />
<br />: unknown
<br />
<br />onset to death
<br />
<br />IMMEDiATE CAUS~:
<br />
<br />IMMEDIAT~ CAUSE (Final
<br />dIsease or condition resulting
<br />in dealh)
<br />
<br />w Natural causes due to old age
<br />
<br />DU~ TO, OR AS A CONS~QU~NCE OF:
<br />
<br />Soquontlolly liS! conditiona, If Ib)
<br />.ny, le.dlng 10 lhe cau.e "sled DUE TO, OR'AS A CONSEQiJ~NCE OF:
<br />on line ..
<br />Enl.r Ih. UNDERLYING CAUS~
<br />(dls..se or Injury Ih.1 Initialed (c)
<br />Ihe evenls resulllng in d..lh)
<br />lAST
<br />
<br />I onsello dealh
<br />I
<br />I
<br />_~L
<br />ansello death
<br />
<br />DUE TO, OR AS A CONSEQU~NCE OF:
<br />
<br />(d)
<br />
<br />18. PART II. OTH~R SIGNIFICANT CONDITiONS-Condilions contribullng 10 Iha doalh but not resulling In Iho underlying oause given in PART I.
<br />
<br />]]Hl'WAS MEDICAL. EXAMINliFl-
<br />OR CORONER CONTACT~D?
<br />
<br />.10 YES 0 NO
<br />_n ___." ,.
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />20, IF FEMALE:
<br />U NOI pragnanl willlin paSl year
<br />o Pregnant alllme of death
<br />
<br />21a. MANN~R OF DEATH
<br />.10 Nalural 0 Homicide
<br />
<br />21 b. IF TRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />o Pedeslrlan
<br />
<br />o Olhor (Spoclfy)
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAiLABLE TO
<br />COMPLETE CAUS~ OF DEATH?
<br />
<br />o AccidenlU Pondln91nvesligallon
<br />
<br />U YES Xl NO
<br />
<br />o Nol pregnanl, bul prognant wllllln 42 day' 01 death
<br />o Nol pregnanl, bul pregnanl43 days to 1 year before dealh
<br />o Unknown if pregnanl within the past year
<br />22a. DATE OF INJURY (Mo.. Day, yr)_ _u]22b' TIME~F IN~UR:
<br />
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />o Suicide U Could nol be delermlned
<br />
<br />220. PLACE OF INJURY-AI home, farm, slreet, laclory, office building, conslruclion slle, elo. (Spocify)
<br />
<br />22d.INJURY AT WORK?
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMB~R, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />SlATE
<br />
<br />liP CODE
<br />
<br />:>;
<br />~:!
<br />,,0
<br />$;;;
<br />~~~
<br />Eo..:>;
<br />0"'0
<br />u c
<br />1;'6
<br />{2~
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<br />
<br />23a. DAT~ OF DEATH (Mo. Day, Yr.)
<br />
<br />:>;>
<br />~~~
<br />"<nO
<br />n~
<br />a.Q. iI:( ~
<br />E(Il(:z
<br />8ffizO
<br />"z::>
<br />.000
<br />~a:O
<br />o ~
<br />00
<br />
<br />24e. On the basi, of examlnalion andlor Invesllgation, in my opinion dealh occurrod al
<br />the lime, date and pi 0 and duo to tho cause(s) slalod. (Signa lure and Tille) "
<br />j4 ___~~Ha 11 County
<br />
<br />24a. DATE SIGN~D (Mo" Day, Yr.)
<br />
<br />JanuarlO-Ou2006
<br />
<br />24b, T1M~ OF DEATH
<br />23:00
<br />
<br />m
<br />
<br />
<br />23b. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />230. TIME OF DEATH
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />23:39 m
<br />
<br />m
<br />
<br />23d, To the besl 01 my knowledge, dealh occurred at Ihellme, dale and ptace
<br />and duolo Ihe cause(s) Slaled. (Signalure and Tille) "
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO TI~~ DEATH?
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />NSENT GRANTED?
<br />
<br />(i NO
<br />
<br />Island. NE 68801
<br />
<br />280. REGISTRAR'S SIGNATURE
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />JAN 1 2 2006
<br />
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