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<br />STATE OF NEBRASKA
<br />
<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 RECORDJ1N FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST~SEcnoNWHlCH IS
<br />
<br />:::;:::~:::::~TORY FOR VITAL RECORDS_!11itiu-i~fd;;;~-
<br />JUL 1 1 2005 JV"f'c'!-ilTANLEY Sc COdPER
<br />ASS1STANt STATE REGiStRAR
<br />2 0 0 5 1 0 0 4 6 HEALtHJ1.ND IjUMANSEFMCI!S
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />&
<br />
<br />.,
<br />,
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND--SUPI"pRT
<br />CERTIFICATE OF DEATH
<br />---- . . ,-.-.
<br />
<br />
<br />74~
<br />
<br />DECEDENT'S-NAME (Flrsl, Middle, Last,
<br />Arthur Lewis Schmidt
<br />
<br />-~- CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY O,;:]BIRTH 5a-AGE-la;1 Birthday
<br />
<br />Hastings, Nebraska (Y,") 75
<br />
<br />- . -
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />Suffix)
<br />
<br />2. SEX
<br />Male
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 17, 2005
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE DF BIRTH (Mo., Day, Yr.)
<br />
<br />Sept. 18, 1929
<br />
<br />8a. PLACE OF DEATH
<br />
<br />508-42-2863
<br />
<br />~Q&.PIJAL:
<br />
<br />o Inp.llenl
<br />
<br />Qll:II;!l: 0 Nursing Home/LTC 0 Ho.pice Facilily
<br />
<br />'''\,
<br />
<br />8b. FACILITY-NAME (II nol In.lltutlon, give .treet and number)
<br />
<br />o ER/Outpollonl
<br />
<br />lD Decedonl'. Home
<br />
<br />Home:
<br />
<br />1365 13 Rd.
<br />
<br />8e. CITY OR TOWN OF DEATH (Include Zip Code)
<br />
<br />Central City
<br />9a. RESIDENCE-STI>:rE
<br />
<br />Nebraska
<br />
<br />68826
<br />_19bCOUN~er-~~~-k
<br />
<br />....- --"
<br />
<br />o IX:l\ OOther(Speelfy)__
<br />
<br />_J8d.COUNTY O~=::ick
<br />
<br />~6RTOWN -
<br />~ Central City
<br />] 9~ APT NO 91. ZIP CODE -~ECITY LIMITS
<br />68826J.~s :Jfl NO
<br />lOb. NAME OF SPOUSE (Fir.t, Middle, Last, Sulllx) It wife, give maiden Mme.
<br />
<br />9d_ STREET AND NUMBER
<br />1365 13 Rd.,
<br />
<br />lOa. MARITAL STATUS ATTIME OF DEATH 0 Married alNever Married
<br />
<br />o Married, but separaled LJ Widowed 0 Divorced LJ Unknown
<br />
<br />11. FATHER'S-NAME (First,
<br />_ _1\d?~J'h
<br />
<br />Middle,
<br />
<br />Last!
<br />
<br />Sulllx)
<br />
<br />~-_t:2
<br />
<br />MOTHER'S-NAME (First, Middle, Maldan Surnomo)
<br />Martha Lisius
<br />
<br />.-----r~~ RELATIONSHIP TO OEC~DE;~
<br />
<br />
<br />Schmid t '""1i";;, 'o~i:;;::'2b05-
<br />
<br />
<br />CITY I TOWN STATE
<br />
<br />Schmidt
<br />
<br />13. EVER IN U.S. ARMED FORCES' Give date. of sorvice il yos_ 14a. INFORMANT-NAME
<br />(Yes, no, or unk.) Yes: 3/17/52 3/16/54 Charles
<br />
<br />15. ;::~.~ OF DI:::~:::~ 16a.EMBAl ~.h/J p!./
<br />
<br />o Cremallon 0 Entombmont 16d_ CEM ERY, CREMATOR~ dlf(E;(OCATION
<br />
<br />o Removal D Othor (Spocify)
<br />
<br />Concordia Cemetery
<br />
<br />Prosser, Nebraska
<br />
<br />17a. FUNERAL HOME: NAME AND MAILING ADDRESS
<br />Apfel Funeral Home,
<br />
<br />PART I. Entar the ~,Qle.Y.e.PI$,--dlseases, injuries, or compllcallons--that direclly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrost, or venlfleular librHlalion wilhout showing Ihe eliology. DO NOT ABBREVIATE. Enler only one caU,O on alina. Add additionalllna, II necessary.
<br />IMMEDIATE CAUSE:
<br />
<br />onset to death
<br />
<br />IMMEDIATE CAUSE (Ftnat
<br />disease or condition resunlng.
<br />In death)
<br />
<br />SequenllallyII.teondlttons,If (b) Heart Failure
<br />any, lesdlng to the <au.eIl9ted -----ouE-TO. OR-AS A CONSEQUENCE OF:
<br />on line e.
<br />Entor the UNDERLYING CAUSE
<br />(dl.ea.e Dr Injury that Inltlat.d (c)
<br />theevenls resulting In death) ---'DUE TO, OR AS A CONSEQUENCE' OF:
<br />I.AS1"
<br />
<br />(0) Cardiac Arrest
<br />
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />
<br />onsel to death
<br />
<br />onset to death
<br />
<br />onsat to deoth
<br />
<br />(0)
<br />
<br />PART II. OHlER SIGNIFICANT CONDITIONS-Condition, conlfibullng 10 Iho doath but not re,ulting In Ihe undorlying cause glvan In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />:lil YES
<br />
<br />o NO
<br />
<br />o Not pregnanl within past year
<br />D Prognant at lime of dealh
<br />o Not pregnant, but prognanl within 42 days of doalh
<br />o Nol pregnanl, but prognant 43 days to 1 yoar boforo doath
<br />o Unknown II pregnanl within Ihe pas I year
<br />
<br />o AcoldenlU Ponding Investigallon
<br />
<br />21b. IF TRANSPORTATION INJURY
<br />o Drivor/Operator
<br />
<br />LJ Passonger
<br />
<br />o Pedoslflan
<br />
<br />o Other (Specify)
<br />
<br />21C_ WAS AN AUTOPSY PERFORMEO?
<br />
<br />20. IF FEMALE:
<br />
<br />21 a_ MANNER OF DEATH
<br />:K) Natural U Homicide
<br />
<br />DYES
<br />
<br />:lQ(NO
<br />
<br />U Suicide 0 Could not be determined
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAilABLE TO
<br />COMPLETE CAUSE OF OEATH?
<br />DYES 0 NO
<br />
<br />22a. DATE OF INJURY (Mo" Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22e. PLACE OF INJURY-At home, farm, slrool, faclory, office building, construcllon site, elO. (Spocity)
<br />
<br />m
<br />
<br />DYES 0 NO
<br />
<br />
<br />22d.INJURY AT WORK?
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO_
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP COO"
<br />
<br />m
<br />
<br />z,.
<br />,..5 ~
<br />J:I~a::
<br />~H
<br />i5.D.oc:[~
<br />E"~Z
<br />o~ 0
<br />"w
<br />1P" :>
<br />~~8
<br />8~
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />June _29, 2005__
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />June 22 2005
<br />
<br />24b_ TIME OF DEATH
<br />
<br />23a. DATE OF DEATH (Mo_, Oay, Yr.)
<br />
<br />.00 a.
<br />
<br />m
<br />
<br />23b. DATE SIGN EO (Mo., Day, Yr.)
<br />
<br />23c_ TIME OF OEATH
<br />
<br />24d. TIME PRONOUNCED DEAD
<br />
<br />23d. To the besl 01 my knowledge, death occurred al the time, dale and place
<br />and due to Ihe eau.o(.) ,taled_ (Signalure ond Tillo) .,
<br />
<br />
<br />m
<br />
<br />25. DID TOBACCO USE CONTRIBUTE TO THE OEATH'
<br />
<br />DYES DNO D PROBAB~Y___1lll UNKNOWN _. _ 0 YE:S ____ X3cNO . _. __ Not Applic.ble 1I_26a i. NO 0 YES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typo or Print)
<br />Anthony D. McPhillips, M rrick Count ,Sheriff 1821 16th Avenue
<br />
<br />NO
<br />
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />
<br />826
<br />
<br />2Bb. DATE FILEO BY REGISTRAR (Mo" Day, Yr.)
<br />
<br />JUL =- ., 2005
<br />
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