|
<br />
<br />~
<br />
<br />STATE OF NEBRASKA
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTIjAti.P:#UMAf!/o~€RVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINA~-IJ1!CQ!'J~tOlYflt.~WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATi~qS"sj}CJJ9.N,'WfiiCtlJS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ..f'f '/~i;i"tI:::""'-~'-;.'\C~
<br />
<br />DATE DF ISSUANCE8.e~~~E~
<br />
<br />FES 1 5 2007 20070 4593 / ASSJlirANT $TATE REGI$TRAfI
<br />LINCOLN, NEBRASKA HEAL'iH A.NpHlJM1:N SERVICES
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE. A....NO. s.tjPPO"~..--""- 2 1 11 9 7
<br />CERTIFICATE OF DEATH .. .::C__'~~ ~ __
<br />~. ~ -
<br />Middle, I.asl, Sulllx) 2. SEX 3. DATE OF DEATlI(Mo" Day, Yr.)
<br />Female Feb,r_~ary 6, 2007 _~
<br />
<br />1. DECI::DEN1"S.NAME (Firsl,
<br />__Loretta Rose Schuyler
<br />
<br />6. DAl E OF BIRTH (Mo. Day. Yr.)
<br />
<br />4. CITY AND STATE OR TEnRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5a. AGI::.Last Blrlhday
<br />(Yrs.)
<br />
<br />5b. UNDEn I YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />Shelby, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />81
<br />
<br />September 22,1925
<br />
<br />B.. PLACE OF DEATH
<br />
<br />506-28-1965
<br />
<br />li9M.!.Thh;
<br />
<br />~ Inp.llenl
<br />
<br />OTHER: 0 Nun;ing HomelUC 0 Hospice Facilily
<br />
<br />0:
<br />~
<br />U
<br />w
<br />0:
<br />is
<br />..J
<br />.,;
<br />0:
<br />W
<br />z
<br />it
<br />
<br />i
<br />
<br />8b, FACILITY-NAME (If not Institution, give slr..1 and number)
<br />
<br />o ER/Oulp.henl
<br />
<br />U Decedenl's Homo
<br />
<br />o Other(Speclfy).
<br />
<br />Uro\
<br />
<br />,
<br />.'0"._____._..____.__
<br />
<br />Saint Francis Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zip Cod.)
<br />
<br />Bd. COUNTY OF DEATH
<br />
<br />Hall
<br />
<br />Grand Island 68803
<br />9.. RESIDENCE.STATE
<br />
<br />9b. COUNTY
<br />
<br />
<br />9g. INSIDE CITY LIMITS
<br />l).:l YES 0 NO
<br />
<br />Hall
<br />
<br />Nebraska
<br />8d. STREET AND NUMBER
<br />
<br />ge.'~-IPCODE
<br />_1~8824
<br />jOb. NAM~ OF Sf'i)USE:: (f-=inl:l. ~iddl@., L!lst, Sulllx) II wife, ~ive maiden name.
<br />
<br />'"
<br />~
<br />~
<br />'a
<br />..
<br />0;
<br />n.
<br />E
<br />o
<br />u
<br />'"
<br />w
<br />~ ~...~oseph K Mic~~k.
<br />
<br />208 W?l~_~__~_.._..__
<br />10a.MARITALSIATUSATTIMEOFDEAIH OMalrled ONeverMarrled
<br />
<br />o Married, but sep~raled llil Widowed 0 Divorced U Unknown
<br />
<br />Adri~n W Schuyler
<br />Sullix) 12. MOTHER'S.NAME (Flrsl,
<br />
<br />Helen Uzendowski
<br />
<br />Middle,
<br />
<br />M.lden Surname)
<br />
<br />11. FATHER'S.NAME (Flrsl,
<br />
<br />Middle,
<br />
<br />Lasl,
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Son
<br />16C. DATE (Mo, Day, Yr,)
<br />
<br />February 1 0, 20_~!__
<br />STATE
<br />
<br />13, EVER IN U.S. ARMED rOnCES? Give dales 01 service if yes, 14a.INFORMANT.NAME
<br />(Yes, no, orunk.) No
<br />15. METHOD or LJISPOSITION
<br />
<br />l.lil Bur,"1 0 Donallon
<br />
<br />
<br />Jlsb LICENSE NO,
<br />
<br />... 1143"
<br />CITY I TOWN
<br />
<br />-;;Lu~
<br />
<br />LJ CremCltion U Enlombrnent
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />U He",oval U Olher (Spetlly)
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />17b. Zip Code
<br />68803
<br />
<br />Westlawn Memoriall Park Cemetery
<br />._~ ..,~-----"'- ."'-- ~~-"
<br />17a. FUNUIAL HOME NAME ANO MAILING ADDRESS (Slteel. City orTown, Slale)
<br />Livingston-SDndermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />
<br />0:
<br />W
<br />LL
<br />~
<br />w
<br />U
<br />
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enler Ihe chain olevenls--dl,eases, injunes, or compllc.llons--lh.1 dlreclly causod II,. dealh. DO NOT enter lermln.levenls such as cardiac arresl, I APPROXIMATE INTERVAL
<br />lespiralory arres!. or vonlllcular fibrillation wllhoul showing Ihe eliology. 00 NOT ABBREVIATE. Enler only one c.use on a line, Add addltion.llines It necessary. I
<br />IMMEDIATE CAUSE: I ;tn'ella dealh
<br />
<br />IMMEOIAT~CAUSE(F~"I ~yvteJtD~~~ ?:~VJfk:'--- L1!,.~et:.___.__.__u____________,_~ 3MtJS. ._~--
<br />
<br />disease or condlllon resulllng OU~ TO OR AS A CONSEOUFNC~ OF on,el to doalh ~
<br />Indealh)
<br />
<br />Sequentially Ilsl condlllons, If (b)
<br />
<br />any, leading 10 Lha causellsled ----OUE -TO:--OR AS A CONSEOU~NCE OF onsollo dealh"' .-
<br />on line a
<br />Enl.r Uw UNDERLYING CAUSE
<br />(dlse.se or Injury Ih.tlnlll.led (c) ~
<br />
<br />tile evenls resulllng In de.th) DUE TO, OR AS A CONSEQUENCE OF: onsello de.lh ---,
<br />LASf
<br />
<br />1(1)
<br />
<br />fB. PART II.;HOER ~~I)CAN~.C::I:O~Ns.conrlihOflS;:lrib~ing 10 Ihe deOh.b~ n~~,res AU/Jlllng in 1I1e underlying CaUse given 10 PART I. -VWAS MEDICAL EXAMINER -,...
<br />
<br />L----' r.u C VI V (PI.' tpU/I.J-t V(,AI,I!- OR CORONER CONTACTED?
<br />
<br />DYES )'{ NO
<br />
<br />R W FEMALE: if. MANNER OF DEATH 2f15: IFTRANSrOR1AlION INJURY"'. WAS AN AUTOPSY PERFORM~O?
<br />
<br />)6 Nol preyn.nlwilhin past year ~.Iural 0 HomrClde OOriverlOpet.lor
<br />o passenge, 0 YES ~O
<br />o Pregnanl allime of dealh 0 AccidenlO Ponding Investigalion
<br />
<br />U Pedeslrlan
<br />U OIl1er (Speolly)
<br />
<br />Yd. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />lJ YES ~~!O
<br />
<br />"'1
<br />
<br />
<br />U Nol p,egn.nL, bUI pregnanl within 42 days 01 deaLh
<br />
<br />U Nol preynanl, bul pregnanl43 days 10 1 ye... belore death
<br />
<br />o Unknown II pregnant wllhlnll1e p.sl year
<br />
<br />o Silicide U Could nol be delermine,1
<br />
<br />22a.IJAlE OF INJURY (Mo" Day, Yr.)
<br />
<br />22b. TIME OF INJURY
<br />
<br />220. PLACE OF INJURY.AI I1orne, f.rm, slreel, 'aolory, ollie. bulldiny, conslruction sile, elc.(Specily)
<br />
<br />In
<br />
<br />22r1. INJURY ATWORK7
<br />
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />
<br />o YES UNO
<br />
<br />221. LOCATION OF INJURY STRl::n & NUMHER, APT. NO.
<br />
<br />ClTYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />." DATE OF DEATH (Mo., D.y, Yr.)
<br />
<br />24a, DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME Of DEATH
<br />
<br />Z>-
<br /><w
<br />,",- Z
<br />..o~o:
<br />-g~O
<br />i5:~~
<br />EY'>-Z
<br />00::1-0
<br />uwz
<br />"'z:l
<br />.000
<br />~o:U
<br />o ~
<br />U 0
<br />
<br />z
<br />'"'<
<br />:gSl
<br />~Ul
<br />li~~
<br />E"-Z
<br />8 goo
<br />QJl:;
<br />-" C
<br />0'"
<br />...~
<br /><i
<br />
<br />m
<br />
<br />24c, PRONOUNCED DEAD (Mo" lJ.y, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On 1I1e basis olexamin.lion andlorinvesllgallon, in my opinion deall1 occurred.1
<br />1I1e time, dale .nd place and due to Ihe c8use(s)slaled. (Signa lUre .nd Tllla) ,.
<br />
<br />2fjlf.WAS CONSI::NT GRANTED?
<br />Nol Applicable II 26a i~..NO 0 YES .~ NO .___
<br />
<br />1&lo.l1d Ne.I.fli:yL);S
<br />
<br />2Bb. DATE FILEO BY nEGISTRAR (Mo. Day, Yr,)
<br />
<br />FEB 1 3 2007
<br />
|