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z a �� <br />.� <br />�- <br />r � n co <br />­4 M 41 -� <br />7z <br />--�-- ,� rn <br />o 2 <br />o <br />I� <br />1111111 4. CITY <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM R'CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAflVYCS 5ECT16ll6- -WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE - ANLEY�SpLCQ�OPER <br />LINCOLN, NEBRASKA 200604267 HEALTH AND tIUNiAIl1 SER."llil S SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVWES* A31117 SIRPORT (� <br />VITAL STATISTICS CERTIFICATE V 1 % <br />4 <br />CERTIFICATE OF DEATH 0 <br />T - NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH (month. Day. Year) <br />Bertha Emma Schuett Female June 27, 2004 <br />STATE OF BIRTH le not in USA.. name country/ 5a. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6- DATE Or BIRTH (Month. Day. Year) <br />Rural Grand Island, Nebraska furs.) 94 56. MOS. DAYS sp. Houas' MINS. September 18, 1909 <br />_......v....,. 8a. PLACE OF DEATH <br />508 -46 -7098 <br />Bb. FACILITY - Name (It not insdtutmn, give street and n <br />Hamilton Manor <br />Be. Cr1Y. TOWN OR LG.ATION OF DE!TN _. ._ <br />Aurora <br />9a RESIDENCE -STATE 96. COUNTY <br />Nebraska Hamilton <br />10. RACE - (e.g., White, Black. American Indian, 11, ANCESTRY le.g.. <br />etd.l)specify( White (specify) <br />14a. USUAL OCCUPATION /Give kind of work done dudng most <br />Wworkinglife.evenitretired) Homemaker <br />16. FATHER -NAME FIRST MIDDLE <br />9c. CITY <br />HOSPITAL Inpatient <br />ER Outpatient <br />DOA <br />8d_ INSIDE CITY LIMITS Be. COUNTY Or DEATH Hamilton <br />Yas No .. ._.. <br />WIN OR LOCATION 9d. STREET AND NUMBER (Includlnq Zip Code) 9e. INSIDE CITY LIMITS <br />Aurora 1515 5th St. 68818 Yes No ❑ <br />1. Mexican, German, atcl 12. 11 MARRIED WIDOWED 13. NAME OF SPOUSE ryt wiln . give maiden name) <br />German NEVER DIVORCED Hans Henry Schuett <br />141). KIND OF BUSINESS INDUSTRY <br />Domestic <br />I ART 7. M( <br />OTHER' ® Nursing Home <br />Residence <br />Other (Specdv, <br />Albert J. Niemoth <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES( 19a. INFORMANT - NAME <br />(Yes. no, or unk.) Ilf yes. give war and dates of services( <br />NO <br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />719 Worms Rd. Grand Island, Nebraska 68801 <br />20- EMBALMER • SIGNATURE 8 LICENSE NO. 21 a. METHOD OF DISPOSITION 21 b. <br /># 1325 <br />®Burial ❑ Removal <br />22a. FUNERAL HOME - AME <br />Apfel- Butler- Geddes Funeral Home Cranial Donation <br />22b. FUNERAL HOME ADDRESS fbi-11 OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />1123 W. 2nd St. Grand Island, Nebraska 68801 <br />F I <br />5EOUEN E OF <br />@) <br />DUE TO. OR <br />(ENTER <br />A <br />15. EDUCATION (Specity only highest grade completed) <br />Elementary or Secondary 10.12) College 11 -4 or 5.1 <br />12 <br />MIDDLE MArUGN <br />Bertha M. Loescher <br />Loren Schuett <br />DATE <br />Jul 1, 2004 <br />CEMETERY OR CREMATORY LOCATION CITY OR TOWN <br />Grand Island, Nebraska 68801 <br />21c. CEMETERY OR CREMATORY NAME <br />Grand Island City Cemetery <br />CAUSE PER LINE FOR la)- (hl, AND IQ <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART EGNANGY IN THE PAST 3 MONTHS( 24 AUTOPSY <br />PART <br />C"rTe_a ,l (Ages 10 -541 Yea No Yes Nc <br />26a. t'v 28c. DATE OJF INJURY /Md- Day Yr 1 286 HOUR OF INJURY M. DESCRIBE HOW INJURY OCCURRED <br />Accident ❑ Undetermined M <br />Suicide Pending 26e, INJURY AT WORK 26f. o(lice 6 3 INBJglY ,Wp farm. street. factory 26g. LOCATION <br />Homicide Investigation Yes 17 No <br />27a. DATE 05 DEATH /Ma. Day. YrJ 28a. DATE SIGP <br />I <br />I <br />II <br />Interval between onset and death <br />I <br />I <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER IORR-ICORONER? <br />Yes I I No De <br />STREET OR R.F.U. NO. �� • �^ �••'• <br />tMo.. Day. Yc) 128b. TIM(Ur' UCAI n <br />June 7,200 r�� 1� _u <br />ji 276. DATE SIGNED (Mo.. Day. Yr.J 2 d. TIME OF DEATH 9 28c, PRONOUNCED DEAD /Ma, Day, YO 28d. PRONOUNCED DEAD /Hour) <br />jig 7 -Z -D X10:30 am M. <br />e 2Be, On the basis W examination and,pr Investigation, in my opinion death occurred at <br />27d. To the best W my knowl0dga. death occurred at the time, data and plgc0 and tlu0 to the the time, data and place and due to the c005e(s( stated. <br />causels) stated. �A n <br />(Signature and Title / ' i" Si nature and Title <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b <br />YES � NO � UNKNOWN <br />�t'E5 NO YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY A7TORNEVI /Type wPrinfl <br />Michael J. Sullivan, M.D. §09 0 St., Aurora, Nebraska 68818 <br />326. DATE FILED BY REGISTRAR oq /ogMa. qay Yr) <br />32a. REGISTRAR J1 �L - 9 2004 <br />M <br />tr <br />41 cr. C <br />4J C: D <br />�F3:J�U <br />W _4 <br />0 b <br />U N <br />4.4 <br />ro w c. <br />>O , <br />��0� <br />O <br />Q r4 <br />roW4� <br />>ra W <br />O <br />El 4.f <br />wr '4-) 0) <br />rrQ��) <br />0 w•� .Y <br />41tV <br />QJ Ql Vi <br />to d Q1 m 14 <br />a r_ .c•H a <br />Q E- F :4 <br />q <br />