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<br />STATE OF NEBRASKA
<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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS7"SI N/HICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. — T
<br />DATE OF ISSUANCE
<br />MAY 3 0 2007 200704592 : - -.t� R
<br />ASSISTANTS
<br />LINCOLN, NEBRASKA HEALTHAN4;l MgR;SFRVII ES
<br />a.;.
<br />STATE of MOPAW — DEPARTMENT of a -4STS - � .M 903
<br />w oR WTAL 9TAT*T c4
<br />CERTIFICATE OF DEATH = --- -
<br />f l D CEDENT - kAw FIRST MIDDLE MY
<br />2. S"
<br />3 DATE p4; YAW
<br />Adrian 141
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<br />UNCEAIRAY I 11-TRFI OF Wyk
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<br />elk PLACE OF MATH
<br />HOSPITAL. FN arpeae. "rt OTHER ❑ M..v Hov e
<br />5-Q6 20 5314
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<br />❑ DOA ❑ Opw16Pac.,
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<br />Grand Island, Ne. YIe ®M0 ❑
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<br />ft RESIDENCE - STATE
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<br />ft. C15. TOWN pR LOCATION
<br />x STREET AND NUMBER I t *m9*WZ0 CXW
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<br />Nebraska
<br />I Hall
<br />Grand Island
<br />Nebraska Veterang Hgag
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<br />t 3 NAME OF SPOUSE M w* tpr wweYe *Mw
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<br />NEVER avvRCED
<br />Loretta
<br />Ids USUALOCCUPAT'gN !C»vledddr,!rAeerl.grwly AnrV 1�
<br />Ne�r+p RlA nyn Yryt6sY1
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<br />_7 1. 0
<br />16. FATHER -NAME FIRST MK)OLE LAST 1. MOTHER FIRST MMDnLE MAIDEN SLNAMAME
<br />(dec) John Schu ler decd Elizabeth Grey
<br />t6 WAS DECEASED
<br />EVER W U. i ARMED FOROEMT
<br />rPr INFORMANT -NAME
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<br />F %Army/X -6- -1 -44
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<br />1fb. INFORMANT MMLM ADDRESS !STREET OR .D. NO.. CITY OR TOWN. STATE. 2NPi -
<br />208 W. Syria, Box 152, Cairo, NE 68824
<br />.MW MER - 5iC 7URE 3 LIC 1 f�� 21r. METHOD OF WPOSIT<w 21b. DATE 11 c. CEMETERY OR CREMATORY . NAME
<br />i ,Jf riS 7
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<br />wis, Jan. 29,1997
<br />u RrPw�a% Westlawn Memorial Park
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<br />a FUNERAL ME 216 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
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<br />Livingston -Son rmanln E.H. ❑co"u sA 1:1 D", Grand Island, Nebraska
<br />2215. FUNERAL HOME AM—Mg 1 TAEET OR F.D. NO.. CITY OR TOWN. STATE. 21P,
<br />601 N. Webb Rd., Grand Island, Ne. 68803
<br />_
<br />23. IMMEDIATE CAUSE !ENTER ONLY ONE CAUSE PER LINE FOR :aI Ib1. AND (all I WrINYM WIa'een erteee and dear!
<br />PART
<br />' faI Cardiopulmonary arrest immediate
<br />- - - -ME
<br />TO. DR AS A CON55QUENCE CW Yimal bellow Mw urd deM6
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<br />The West Half (W1 /2) of Lots Seven
<br />(7) and
<br />Eight
<br />(8), Block Five (5),
<br />Fourth
<br />Addition to
<br />Cairo, Hall County, Nebraska.
<br />STATE OF NEBRASKA
<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 RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS7"SI N/HICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. — T
<br />DATE OF ISSUANCE
<br />MAY 3 0 2007 200704592 : - -.t� R
<br />ASSISTANTS
<br />LINCOLN, NEBRASKA HEALTHAN4;l MgR;SFRVII ES
<br />a.;.
<br />STATE of MOPAW — DEPARTMENT of a -4STS - � .M 903
<br />w oR WTAL 9TAT*T c4
<br />CERTIFICATE OF DEATH = --- -
<br />f l D CEDENT - kAw FIRST MIDDLE MY
<br />2. S"
<br />3 DATE p4; YAW
<br />Adrian 141
<br />1. Cm' AMCSTATEOF TH 4rorNU.SA.ww4pwrp
<br />ft ARE -t,ap 1YEAR
<br />UNCEAIRAY I 11-TRFI OF Wyk
<br />Elyria, Nebraska
<br />n,.l 73 Se IDS. I DAYS
<br />AINs September 17. 1923
<br />7, SOCPAL SECUFMY MUMSER
<br />elk PLACE OF MATH
<br />HOSPITAL. FN arpeae. "rt OTHER ❑ M..v Hov e
<br />5-Q6 20 5314
<br />❑ EROagaera ❑ RFrdnr,A
<br />/k FACl1TY -NIAte
<br />VA Medical Center
<br />❑ DOA ❑ Opw16Pac.,
<br />CITY. TO" ON LOCAT*111 W - TH
<br />-
<br />Grand Island, Ne. YIe ®M0 ❑
<br />Hill
<br />ft RESIDENCE - STATE
<br />ID CO j
<br />I
<br />ft. C15. TOWN pR LOCATION
<br />x STREET AND NUMBER I t *m9*WZ0 CXW
<br />on 011M dry �rr►s
<br />Nebraska
<br />I Hall
<br />Grand Island
<br />Nebraska Veterang Hgag
<br />I M' ❑
<br />+0 RACE - M.f• Vow sleelr. Ad ~ VOW
<br />11, A14MTW Ie.9 .. ftwS ura"A G Vff4iq, ell:l j
<br />I., fM MIAkq= ('-' -1 WIDOWED
<br />t 3 NAME OF SPOUSE M w* tpr wweYe *Mw
<br />«clrsoeuyl white
<br />4whill Dutch /German
<br />I
<br />NEVER avvRCED
<br />Loretta
<br />Ids USUALOCCUPAT'gN !C»vledddr,!rAeerl.grwly AnrV 1�
<br />Ne�r+p RlA nyn Yryt6sY1
<br />116. KIND OF BUSINESS INDUSTRY r,\
<br />\EaWrr^
<br />�_
<br />1S. EDUCA7gN ISprA bM n I�!"aft WWWM
<br />_
<br />�, p121 COMA Ili ar 5-1
<br />t
<br />�NI'
<br />Mechanic /Attendent
<br />Gas
<br />& Serv�ire S a one
<br />`de
<br />16. FATHER -NAME FIRST MK)OLE LAST 1. MOTHER FIRST MMDnLE MAIDEN SLNAMAME
<br />(dec) John Schu ler decd Elizabeth Grey
<br />t6 WAS DECEASED
<br />EVER W U. i ARMED FOROEMT
<br />rPr INFORMANT -NAME
<br />IYa old. ar u+KJ
<br />yes
<br />ere
<br />F %Army/X -6- -1 -44
<br />43/5
<br />Loretta Rose Schuyler
<br />y�
<br />1fb. INFORMANT MMLM ADDRESS !STREET OR .D. NO.. CITY OR TOWN. STATE. 2NPi -
<br />208 W. Syria, Box 152, Cairo, NE 68824
<br />.MW MER - 5iC 7URE 3 LIC 1 f�� 21r. METHOD OF WPOSIT<w 21b. DATE 11 c. CEMETERY OR CREMATORY . NAME
<br />i ,Jf riS 7
<br />I
<br />wis, Jan. 29,1997
<br />u RrPw�a% Westlawn Memorial Park
<br />,I
<br />a FUNERAL ME 216 CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />r
<br />Livingston -Son rmanln E.H. ❑co"u sA 1:1 D", Grand Island, Nebraska
<br />2215. FUNERAL HOME AM—Mg 1 TAEET OR F.D. NO.. CITY OR TOWN. STATE. 21P,
<br />601 N. Webb Rd., Grand Island, Ne. 68803
<br />_
<br />23. IMMEDIATE CAUSE !ENTER ONLY ONE CAUSE PER LINE FOR :aI Ib1. AND (all I WrINYM WIa'een erteee and dear!
<br />PART
<br />' faI Cardiopulmonary arrest immediate
<br />- - - -ME
<br />TO. DR AS A CON55QUENCE CW Yimal bellow Mw urd deM6
<br />b, Chronic obstructive pulmonary disease 'Years
<br />Arteriosclerotic cardiovascular disease
<br />Years
<br />OTHER ;,IGN7I�FIC /AST C pTryK]NS ID Ite drMhyuf.�(M rW d PART III IF' FEMALE WAS rHe e A i1 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL
<br />PART GERD ? ?eTr� - -cu� ac`c?re6* s/ PPI:GInANCYIN THE PAST ,) Mftr:THS1 I OH CORONER'
<br />_ Hypertension I:.I.T0 -SAL Yes M —N° ❑j Yep i Iq YeA 0 N, ®�_
<br />�a 26D. DATE OF INJURY /Akr GY 2Qc HOUR OF INJURY T2rd DE5i:RISE HOW INJURY OCCURRED
<br />C� A.,c*M ❑ U14e4rmined
<br />❑ S..,c.de ❑ Pwdtng 1 28e !NJUR4 AT WO�:4CLS;,LZj.URV M rEVre Parm ;Orr! factvY 25g LOCATF7ry STREET OR R.F.D NO CITY OFi Tpryry SPATE
<br />Na cry!
<br />� 6 DATE OF OEATN 1Mp. Doy YII T ' 29a ,')ATE SIGNED J M n D a y V. r 12M IrW OF DEATH
<br />January i
<br />25, 1997 _ M
<br />74 arm.. UATE S4DNED (Mb Day n, 27c TIME OF DEATH 2&. PRONOUNCED DEAF tw Coy, ✓ ; 2PA PRONOUNCED READ /Hwl
<br />�1I I January 26, 1997 9:43 M
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<br />Tr1 brit rLyOACCO USE CONY 7S Tp YNE DEATH? 30.a Hn57f GArd OP TI$SUE DONATION SEEN CONSIDERED? 3615 WAS CONSENT GRAN", tcD'
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