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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STA TE DEPARTMENT OF HEAL TH, <br />"CERTIFIES THE BELOW TO BE A TRUE COpy OF AN ORIGINAL RECORD ON FILE W"H THE STA TE <br />DEPARTMENT OF HEAL TH, BUREAU OF V"AL STA TISTICS, WHICH IS THE LEGAL DEPOS"ORY FOR <br /> <br /> <br /> <br />A:~U;G; :2;:u1995:~CE 20051004 6 ~j~~ <br />AS~AN~r::J:'E.REGl$1'RA~ <br />LINCOLN, NEBRASKA NEBRAS~' o.EPARTM~NT OF HEAL T~ <br /> <br />.<\ <br /> <br />STATE OF NEBRASKA - DEPARTMENT'OFHEAtrH <br />BUREAU OF VITAL STATISTICS c._ <br />CERTIFICA TE OF DEATH <br /> <br />Rudolph <br /> <br />Clarence <br /> <br />Schmidt <br /> <br />Male <br /> <br /> <br />August 12, 1995 <br /> <br />1 DECEDENT - NAME <br /> <br />FIRST <br /> <br />"'IDDlE <br /> <br />LAST <br /> <br />< SEX <br /> <br />;3. ':!.'}PrlE OF OEATH IMartttl. Day YfI(Ir) <br /> <br />. CITY AND STATE OF 61RTH mno/inuS~ Mm''''OUnlrtl <br /> <br />Juniata Nebraska <br /> <br />50. AGE - l.asl 6o<1hOay <br />IV'll I 82 <br /> <br />UNDER 1 VEAR <br />~ "'OS DAVS <br /> <br />U~OER I 0.- v <br />50. HOlJRS <br /> <br />6 O,lTE OF: BIRTH IMont!l. Day Year) <br /> <br />August 22, 1912 <br /> <br />':..11 7 SOCIAL SECURTIV NU",aER <br />". <br />-1 <br />n <br />..1 8b FACllITV. Name (If not 1fJ5IWIion. fJllIfI slrfHJt ana numbBrJ <br /> <br />:~ Park Place Nursing Home <br />8c CITV.TOWNORlOCATlO..6fWTH--..- <br /> <br />505-48-7308 <br /> <br />Sa PLACE OF DEATH <br />~SPtT Al @ lopaIIOIO <br />o ER 0\rtp0berI <br />o OOA <br /> <br />Q!.~11 0 NurSIng Home <br /> 0 ReStoenc@ <br /> 0 Other (StJecIJvI <br /> <br />11 ANCESTRY (e,g., 1IaJi8(I. MelCtcan. German, etc:l <br />15<>o<'1y1 German <br /> <br /> <br />9d STREET AND NUIoMlER Ib>cWNlg Z'p CoGel <br /> <br />"" INSIDE CITY U"'ITS <br /> <br />eo INSIDE CITY UMITS <br /> <br />Grand Island <br />8a RESIDENCE. STATE <br /> <br />Nebraska <br />10 RACE. ".9.. Whole. 61eCk AmthCOll_ <br />0lC1I5<>o<White <br /> <br /> <br />150th Rd. 6888 <br /> <br />v.. 0 No I&} <br /> <br />13 NAME: OF SPOUSE ilf IN/Ie. ptVfl mIJidrM'I flame) <br /> <br />Mable <br /> <br />Gosda <br /> <br />14a USUAl OCCUPATION IG....ond '" _ <Jane dunng mos' <br />I~:J "'_onglilo._d_, <br />::I Farmer <br /> <br />Agriculture <br /> <br />,~ EOUCA.llON !~Ify only highest fade COf'(Jpletedl <br />~, 5ec:o"tdary (0-121 ~.f1.. Of ~~I <br /> <br />n. 16. FATHER - NAME FIFiST MIDDlE LAST <br />.-... <br />_I Adolph Schmidt <br /> <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES' <br />lYe'$,. no or ur'Ik-l '" yes, gIve war am dafes of S8MCesl <br />NO <br /> <br /> <br />17 lIOTHER <br /> <br />MIDDLE <br /> <br />MAIDEN SURNA"'E <br /> <br />Martha <br /> <br />Lisius <br /> <br />NAME <br /> <br />Mable <br /> <br />Schmidt <br /> <br />191> INFORMANT <br /> <br />MAILING ADDRESS <br /> <br />ISTREET 0f'I R.F D NO., CITY OR TOWN. STATE. ZlPI <br /> <br />12360 S. 150th Rd. Wood River, NE. 68883 <br /> <br /> <br />21. METHOD OF DiSPQSITION 21b DATE <br /> <br />Z,c CE"'ETERV OR CREMA TORy N-""'E <br /> <br />~BU"aJ o Romova' Aug 15, 1995 Concordia Cemetery <br /> <br />21d CEMETERV OR CRE"'A'O<!Y LOCATION CITY OR TOWN STATE <br /> <br />Apfel Funeral Home <br /> <br />OC- 00000>00 <br /> <br />Prosser NE <br /> <br /><Zb FUNERAl HOME ADDRESS <br /> <br />ISTREET OR R.F.D. NO.. CITV OR TOWN. STATE.ZIPI <br /> <br />Wood River , NE 68883~126 <br />_ 23 ''''MEDIATE CAUSE IENTER ONL v ONE CAUSE PER UNE FOR 101101, AND lell <br />P~RT CliP <br />!!I lal <br /> <br />~ 'b~UEr:,;;;;J;::~ ~~ S;c!.uc-VfI/Jl.c-(JKW.I~ - ~d ' <br /> <br />DUE TO OR AS A CO<l!;EOUENCE OF r- ------.-.. . <br /> <br />Interval between onset and aealr, <br /> <br />s~ <br /> <br />Inter....al be1ween onset and dealh <br /> <br />~r- <br /> <br />.... <br /> <br />Interval between onset arid rlF.!alh <br /> <br />lei <br />OTHE~ SIGNIFfCANl CONOltlONS - CMcIiflons C;l)nttibuting 10 the death but not related <br />PART il- _ ^ <br />II rr::>L. 1.I f.J <br /> <br /> <br /> <br />260 DATE OF INUuRv IMe. Doy. Y,.I 26c HOUR OF INUURV <br /> <br />260 <br /> <br />o AcCloenl 0 l,Jndelermme(;l <br />o SUICIQe 0 PeM't\9 26e INJURY AT WORK: <br />o HomIC1de <br /> <br /> <br />STATF" <br /> <br />~8 (lAtE SIGNED -"Me D.h .' i <br /> <br />200 TIME OF DEATH' <br /> <br />z~ <br /> <br />~! i ~ ~ i ~ ~ ~ 2ac PRONOUNCED DEAD ..\00 08,. y, 200 PRONOUNCED DEAD (Hood <br />~~~~ !~~~ <br /> <br />; ~ f Z7d To....... 01 my knO"""'ge~ne at... "mo. dale and ""C9 ano duo 10 ltIe '" ~ ! ~ 280. On "'" ....,. 01 .,.~ ."" '" ~_, ,n my opinion d.aln necu,,"" " <br />= ... tau5elsl statec1. ,IJ/) 3 is tne IHne. elate a~ pAaiO! at'(:) 0U@'101ne eaLJSe(SI sta.h!Id <br /> <br />r-- I~ature and Tlftel ., nature and Tltlel <br />- 29-.-t5'O'l'OaAcc6- USE CONTRI6UTE TO THE OE-" TH' :)(I. HAS ORGAN OR TISSUE DONAT1ON 6EEN CONSlDEREO' 30.0 WAS CONSENT GRANTED? <br /> <br />o YES Ii(! NO 0 UNKNOWN 0 YES '&J NO D YES ~ NO <br /> <br />31 NAME AND ADDRESS Of CERTIFIER IPHVSICIAN, CORONER'S PHySICIAN OR COUNTY ATTORNEV, I TV"" ()I Pnnl/ <br /> <br />M <br /> <br />'" <br /> <br />32.. REGISTRAR <br /> <br /> <br />2116 W. FaidIe <br /> <br />Av. #400 Grand Island Ne <br />,- DATE FlLfAlf;r2"A2199t{1 <br />