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<br />WHEN 7HIS COpy CARRIES THE RAISI!D SEAL OF THE NEBRASKA HEAL TH ANIJ}:IU'!!AJt~i{RYJfES,,,
<br />SYSTEM,IT CERnFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL ~COBDcONFUWI!H "~;\' ,', '
<br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA TISricsSEcTION, wH1CH'fS-_: ~.)'"
<br />-.. ,-, ',--. ~." .....l'.J'
<br />
<br />
<br />~TE:~:;~;TORYFOR;;l:;; 8.~ !:!tlit::f!iU ',;
<br />
<br />HEALTHANDH~R~~~~
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />STATE OF NEBRASKA~ DEPARTMENT OF HEALlH AND HUMAN SERVICES.FmANcr Mm. sUPPoRT
<br />VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />
<br />03
<br />
<br />00634
<br />
<br />, DECEDENT-- NAMo
<br />
<br />FIRSI
<br />
<br />MIDDLE::
<br />
<br />LAST
<br />
<br />2 SEX
<br />
<br />3. DATE OF DEA lH IMOIIrh Uav. Y~ar)
<br />
<br />George
<br />
<br />Vincent
<br />
<br />Schutte
<br />
<br />Male
<br />
<br />
<br />January 17, 2003
<br />6 DATE OF BIRTH (Month. Day. Year)
<br />
<br />4 CITY AND STATE OF BIRTH IIf (lot irl u.s.A.. flame cour'llry)
<br />
<br />53 AGE. Last Birthday
<br />{Yes. I 88
<br />
<br />UNDER 1 YEAR
<br />5" MDS I DAYS
<br />I
<br />
<br />UNOER 1 DAY
<br />5c. HOURS MINS
<br />
<br />January 25, 1914
<br />
<br />Lawrence, Nebraska
<br />:--;-SOOAlSEcljfiTiYNUi;;;lfR-~'-~-"""-
<br />
<br />702-14-3973
<br />
<br />8a Pl.ACE OF DEATH
<br />HOSPITAL: [Xl Inpatient
<br />
<br />D ER Outpatient
<br />
<br />D DOA
<br />
<br />OTHER. D NurSing HOrlie
<br />
<br />D Reslder'lcc
<br />
<br />o OIMr (Specdvl -'~_~
<br />
<br />Bb F ACtLlTY - Name (If nQ/ Inslilutian. give street and number)
<br />
<br />St. Francis Medical Center
<br />
<br />German
<br />
<br />
<br />
<br />8d INSIDE CITY ~ 8e
<br />
<br />Yes CXI No 0 .
<br />CIl Y, TOWN OR LOCATION
<br />
<br />COUNTY OF DEATH
<br />
<br />: Bt CIIY fOWN OR L.OCATION OF DEAfH
<br />
<br />Grand Island
<br />
<br />9a. RESIDENCE - STATE
<br />
<br />
<br />9d. Sl~E.t:.T AND NUMBER (Inc/udingZifJ Code)
<br />
<br />Nebraska
<br />
<br />Hall
<br />
<br />Grand
<br />
<br />68801
<br />
<br />ge INSIDE CITY LIMITS
<br />
<br />Yes KJ No D
<br />
<br />10.
<br />
<br />11. ANCESTRY le,g Italian. MeXican, Getman, elc:1
<br />fSpaclfyl
<br />
<br />13 NAME OF SPOUSE tI! wife, give maiden name)
<br />
<br />elc.IISpecllyl White
<br />
<br />14a USUAL OCCUPATION {GIV~ klfi(! 01 work dofle (Jut/rtg mOSI
<br />of WOf'k/flg life, even II fetifedl
<br />Farmer
<br />
<br />Eleanor
<br />
<br />Brockman
<br />
<br />16. FATHER. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />Agriculture
<br />LAST 17 MOTHER
<br />
<br />(SpeCify only nIghest grade completM)
<br />Elemenlaryt2Secondary fO. 121 College !' 4 Of ~. I
<br />
<br />MIDDLE
<br />
<br />MAIDEN SURNAME
<br />vi
<br />Ven Haus
<br />
<br />Jospeh
<br />
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />IYes. no. Or unk.) III yes. give war and elates 01 servicesl
<br />No
<br />
<br />
<br />Mary
<br />
<br />Eleanor
<br />
<br />Schutte
<br />
<br />'9b INFORMANT
<br />
<br />MAIl.ING AODRfSS
<br />
<br />ISTREET OR RFO. NO.. CITy OR TOWN STATE. zIPj"-----
<br />
<br />619 West 14th,
<br />
<br />Grand Island, NE.
<br />
<br />68801
<br />
<br />
<br />"-'-'-, J L 21."METHOD OF DISPDSIlIDN . '"' b. DATE
<br />[Xl BUrial D Remov(ll J an.
<br />
<br />21 c~C['M.ETEAY ~"i()HY-.'-NAMI::
<br />
<br />20,
<br />
<br />2003
<br />
<br />Westlawn Cemetery
<br />CITy OR T6wN----'.--~""STAT.~....'
<br />
<br />2'" CEMETERY OR CREMATORY LOCATION
<br />
<br />o Cremation 0 Oona'lo~
<br />
<br />Grand Island, NE.
<br />
<br />22" FUNERAL HOME ADDRESS
<br />
<br />{STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIPI
<br />
<br />1123 West Second.
<br />
<br />23 IMMEtcECAUSE ~.---.-- .
<br />PART 1 .
<br />
<br />I,al ~
<br />DUE TO. f'Y A NSEOUENCE OF ~
<br />
<br />1"1 '\ '\., "-
<br />DUE TO. OR AS A CONSEQuENCE OF:
<br />
<br />Grand Island, NE.
<br />
<br />68801
<br />
<br />
<br />ONLY ONE CAUSE PER LINE FOR 131 '''1. AND (cl)
<br />
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />I
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />
<br />
<br />~
<br />\" V'<>--!,,,,,~,,,,,--
<br />-.-.---
<br />
<br />26a
<br />0 Accident D Undetermined
<br />0 S\Jicide D Pendlnq 2Re
<br />0 tiomicide Investigation
<br />
<br />
<br />Np
<br />
<br />
<br />?6g. \ DCATION
<br />
<br />SlREEl OR R.F.D. NO
<br />
<br />CITY on TOWN
<br />
<br />STME
<br />
<br />273. OA TE OF DEATH (Mo" Day. Yr.)
<br />
<br />28. DATE SIGNED IMo, D.v yo
<br />
<br />28" TIME OF DEA Hi
<br />
<br />January 17,
<br />
<br />2003
<br />
<br />M
<br />
<br />~ l:j' ~
<br />"i:Q
<br />: !~ ~
<br />_ 8 ~,I'i
<br />d~
<br />i .... ~
<br />
<br />Zr
<br />_ 0:( UJ
<br />~, 0 Z
<br />j !C ;;; ~8c, PRONOUNCED DEAD /Mo Day. Yr,1
<br />a.g: ~:-;
<br />
<br />January 21, 2003 12: 06A M H ~ g
<br />
<br />27d. To the bast: Of.my kriO~';;I;dgc. d. eath. occurrod at tl'le lime, rn\ and pli:lc::e a~d duo to the :l. ~ ~ 28e. On 1M basis 01 examination and Or inv$Sllg<lhOri. in my opinion
<br /> de;;llt1 OCCllrred at
<br />.... causetsl stated. I ''\ ----:::--- l ~ '.. 0 ., the time. dale and place and due to the c!lusalsl staled.
<br />
<br />r ISlgna\lJfe and Title) ". '--'\...J ,.J - .,~ (51 nature and Title ...
<br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30' HAS ORGAN OR TISSUE IlONATlON BEEN CONSIDERED?
<br />
<br />DYES D NO .~ UNKNOWN D YES NO
<br />
<br />31 NAME AND ADDRESS OF CERTIFIER IPHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY I Iry"" Of P"nI!
<br />
<br />M
<br />
<br />27b. DATE SIGNED (Mo D.:JY Yr I
<br />
<br />27r;. TIME OF DEATH
<br />
<br />2M PRONOUNCED DEAD IHou"
<br />
<br />Jo.t) WAS CONSENT GRANTED?
<br />DYES
<br />
<br />~ NO
<br />
<br />W. J. Landis
<br />32. REGISTRAR
<br />
<br />M.D.
<br />
<br />
<br />Grand Island NE 68803
<br />32b DATE FILED By REGISTRAR IMo" Day Y'.j
<br />
<br />JAN 2 7 2003
<br />
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