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<br />Lo.t 2, Block 4, Normandy Es ta tes, an addi tion to the Ci ty of
<br />Grand Island, Hall County, Nebraska
<br />
<br />WHEN THIS copy CARRIES THE RAISED SEAL OF T.HE NEBRASKA HEAL TH AND HUMAN SERVICES
<br />SYSTEM, "CERTlFIES THE BE40W TO BE A TRUE COPY OF THE ORIGINAL RE"Olffi'01(FJLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST/~~/CH)S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. . ~-?"'. ","C~ #.' ~~j~=,
<br />
<br />
<br />'6i3/2003 200710092 ~~~~
<br />ASSt$TANT SmE-M6I!sTAARt::
<br />LINCOLN, NEBRASKA HEALTH AND ~N ~,!~~~,-,~y'S~"t'
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTII AND HUMAN SERVli::l1,$;.BN~~iJPi>RT
<br />CERTI~~~~~~EATH ...:-, ~.~ ~ o~~-U'"3 061 2 'I
<br />
<br />1. DECEDENT. NAME
<br />
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />2: SEX
<br />
<br />{MOnth. Oay, Year)
<br />
<br />Edmund
<br />
<br />Harold
<br />
<br />Schlund
<br />
<br />Male
<br />UNDER 1 DAV
<br />5c. HOURS" MINS.
<br />
<br />4, CITY AND STATE. Oi= BIRTH (If no' in U.SA, name country)
<br />
<br />5a, AGE ~ Last Binhday
<br />(VIS.I
<br />
<br />UNDER 1 VEAR
<br />5b. MOS. I DA VS
<br />I
<br />
<br />Cairo, Nebraska
<br />7. SOCIAL SECURTIV NUMBER
<br />
<br />68
<br />
<br />1934
<br />
<br />Ba. PLACE OF DEATH
<br />HOSPITAL: D Inpatient
<br />D ER Outpati@:lnl
<br />D DOA
<br />
<br />OTH~.~; D Nursing Home
<br />KJ ResidenCe
<br />
<br />o Other (SPBClf\l1
<br />
<br />505-38-5227
<br />8b. FACILITY. Name
<br />
<br />{If ~ot llistitu#on, give 5trf*/f ana nvmoetJ
<br />
<br />1523 Windsor RClad
<br />
<br />8e. CITV. TOWN OR LOCATION OF DEATH
<br />
<br />
<br />Bd. INSIDE CITY LIMITS
<br />
<br />Grand Island
<br />
<br />
<br />9.. RESIDENCE" STATE
<br />
<br />(Including Zip CadS)
<br />
<br />9e!, INSIDI;; CITY LIMITS
<br />
<br />68801 v.. [Xl No D
<br />
<br />(If wif8. giV8 maiden name)
<br />
<br />Nebraska
<br />
<br />atcllSp.Cltyl Whi te
<br />
<br />11. ANCESTRV '..g..
<br />ISP8Ci~
<br />GenIlan
<br />
<br />l4b. KIND OF BUSINESS INDUSTRV
<br />
<br />14a. USUAl OCCUPATION (Give klndcfworl( done during most
<br />of workiflq life. even il refiredJ
<br />Postal Carrier
<br />
<br />Government
<br />LAST
<br />
<br />MAIDEN SURNAME
<br />
<br />16. FATHER. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />17. MOTHER
<br />
<br />Harold
<br />
<br />
<br />Mar aret
<br />
<br />Veeder
<br />
<br />16. WAS DECEASED EVER IN U.S. ARMED FORCES7
<br />(Yes. rto. or unk.) lit yes. give war and dates of services)
<br />Yes Korea 10/27/54-5/27/56 Schlund
<br />181>. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIPI
<br />
<br />1523 Windsor Road
<br />
<br />Grand Island NE 68801
<br />21a. METHOD OF DISPOSITION 21 b. DATE
<br />
<br />21e. CEMETERV OR CREMATORV NAME
<br />
<br />
<br />#/~dlS-
<br />
<br />5/:27/03
<br />
<br />o Burial 0 Removal
<br />
<br />Cent. Nebr. Crem. Serv.
<br />
<br />21d. CEMETERV OR CREMATORV LOCATION
<br />
<br />CITV OR TOWN
<br />
<br />Apfel Funeral Home
<br />
<br />~ Cremation 0 Donation
<br />
<br />Gibbon, NE
<br />
<br />22b, FUNERAL HOME ADDRESS
<br />
<br />(STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />
<br />411 West 11th Street p.O. Box 126 Wood River,
<br />23. IMMEDIATE iAUSIiil ,,{ENTER ONL V ONE CAUSE PER LINE FOR lal. (bl. AND (clI '
<br />
<br />P~R:I x: J- \ Vt- (L ffrl ~
<br />{b~UETO~C~ETm1C ~ \ vFtZ
<br />
<br />DuE ro, OR AS A CONSEOUENCE OF'
<br />
<br />~DPAA~
<br />
<br />NE 68883
<br />
<br />I Inlerval between onset and deall1
<br />
<br />: Ii lS1.>e MbtU"fH
<br />I Interval between onset and deatl1
<br />I
<br />__"_._ ~-.l..!J'Ne ~ E-A€
<br />I Inlerval between Onset and d~~lh
<br />I
<br />: >'iWO 't W---S
<br />
<br />25. WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER"
<br />
<br />GfrivCFZ-
<br />wfL
<br />
<br />
<br />26a.
<br />0 Accident 0 Undetermined
<br />0 Suicide 0 Pi:!nding
<br />0 Homicide Inllestigalion
<br />
<br />26b. DATE OF INJURV (Me.. Day. Vr.) 26c. HOUR OF INJURV
<br />
<br />26.. INJURV AT WORK
<br />Yes 0 NO D
<br />
<br />28g. LOCATION
<br />
<br />STREET OR R.F.D. NO.
<br />
<br />CITY OR TOWN
<br />
<br />28.. DATE SIGNED (Mo.. Day Y'.I
<br />
<br />28b. TIME OF DEATH
<br />
<br />~.~
<br />~~
<br />1">->-
<br />u~g
<br />.! 1l
<br />"'!lI
<br />
<br />~H
<br />1~i5
<br />II=>-
<br />...,~
<br />~~~
<br />!wz
<br />d~
<br />0-
<br />u 0
<br />
<br />288. On the ba.sis of 8~amination and10r investigarion, in my opinion death occurred at
<br />the time. date and place and due to the causelsl Slated,
<br />
<br />28e. PRONOUNCED DEAD (Me" Day, Yr.1
<br />
<br />2Bd. PRONOUNCED DEAD (Houri
<br />
<br />M
<br />
<br />(SI nature and Titlel ..
<br />28. DID rOBACCO USE CONTRIBUTE ro THE DEATH?
<br />
<br />D~ D~ ~~~ D~
<br />
<br />31. NAME AND ADDRESS OF CERTIFIER [pHVSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEVI (rype or Printl
<br />
<br />30.b WAS CONSENT GRANTED?
<br />o YES ~NO
<br />
<br />Peter Ledakis M.D.
<br />
<br />2116 West Faidley Ave.,
<br />
<br />Grand Island, NE 68803
<br />32b. DATE FILED BV REGISTRAR {Me., Day. Yr.)
<br />
<br />32a. REGlsrRAR
<br />
<br />
<br />JUN 2
<br />
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