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<br />....
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEA~),~if~aM.4tJ".~ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB~I(ff:. tigpp,IR"tMfijVI1qF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSlT06 FeR '{fTN. R~jDS, ."" "
<br />,'N;~~~:" Of~~~L
<br />DATE OF ISSUANCE t'~"''^lf-. _ . ,~
<br />
<br />NOV 0 5 2008 200809610 ,'~~fi~Ni~Af;&I~!~i~~
<br />D~p'A.RTMENT QR I1liL TJ-f Ift;r:t,
<br />LINCOLN, NEBRASKA - HtJM.~ .ffRVItES , '" .,.' C:~, ,:"
<br />.- ....t!'Dn! r:\\-',' ",'_",
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES, , 0 8 \'3 O. 'it n:S
<br />leA TE n.:-;;;';';;;': ;";;', ,. ::;.;;;T
<br />
<br />~~
<br />
<br />Eugene Joseph Schneberger
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br /> 2. SID! 3. DATE OF DEATH (loIo.,Day,Yr.)
<br /> Male October 29, 2006
<br />~a. AGE.Lnt Birthday Db. UNDER 1 YEAR ~c, UNDER 1 DAY D. DATE OF BIRTH (1010.. Day, Yr.)
<br />(Y...) MOS. I DAYS HOURS I MINS.
<br />76 August 26, 1932
<br />
<br />1.DECEDENT'S.NAME IFlnol, Mlddla, Laat, SuffiA)
<br />
<br />Seward, Nebraska
<br />7. IOCIAL Sl!CURlTY NUMBER
<br />
<br />506-36-2442
<br />
<br />.
<br />
<br />aa. PLACE OF DEATH
<br />J1Q2IIAL; IiiIlnpaUant
<br />o ERiOUtpaUant
<br />OOOA
<br />
<br />~O Nunolng HDlMlLTC
<br />
<br />o Hoaplca Facility
<br />
<br />..e
<br />
<br />~ ._ _lb. FACILITY-N~_~E (tt not Institution, give Btre8t_~~~ ~;~~~r) _
<br />
<br />o Decedenr. Home
<br />
<br />Saint Francis Medical Center
<br />
<br />o Other(lIpaclfyl
<br />
<br />C
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<br />W
<br />Z
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<br />Gl
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<br />i5.
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<br />Gl
<br />a:I
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<br />I-
<br />
<br />Ie. CITY OR TOWN OF DEATH Ilncluda ZIp Coda)
<br />Grand Island 66603
<br />
<br />lad. COUNTY OF DEATH
<br />Hall
<br />
<br />'a. RESlDENCl!~TATe lib. COUNTY lac. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />ad. STREET AND NUIoIBER I aa. APT. NO. IlK. ZIP CODE
<br />1740 S. Garland I 68803
<br />lOa. MARITAL STATUS AT TIME OF DEATH iii Marrl.d 0 N..er M.rrI.dll0b. NAME OF SPOUSE (FI..~ Mlddl., Lnt, Suffixlltwlf., gl.. "",Id.n nam'.
<br />o loI.rrI.d, but ..paroted 0 WIdowed 0 Di.orc.d 0 Unknown I Janice Matzner
<br />
<br />11. FATHER'S-NAME (Flnol, Mlddl., LI'~ Suffix) 112. MOTHER'S.NAME IFlret, Mlddl., Mlld.n Su""'.....)
<br />Joseoh Schneberoer Frieda Lindner
<br />13. EVER IN U,S. ARMED FORCES? GI.. dat.. of ....Ie. if y...ll4a. INFORMANT.NAME
<br />(Y.., Na, ar Unk.) No I Janice Schneberaer
<br />18. METHOD OF lllSP08ITION 16a. EMBALMER.SIGNATURE
<br />OB.rlal OOo"""on
<br />[ilCnllmUlaQ OEntombrniln1
<br />o Rom..ol OOlllort.......'
<br />
<br />. 11Ig. INSIDE CITY LIMITS
<br />I liD Yn 0 No
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />
<br />Not Embalmed
<br />
<br />T lDb. LICENSE NO.
<br />
<br />16C. DATE (Ma.. D.y, Yr.)
<br />
<br />October 30, 2008
<br />
<br />lid. Cl!METERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITYfTOWN
<br />
<br />STATE
<br />
<br />Central Nebraska Cremation Service
<br />
<br />Grand Island
<br />
<br />Nebraska
<br />
<br />17b. ZIp Cad.
<br />68801
<br />
<br />17.. FUNERAL HOME NAME AND MAILING ADDRESS (St...~ City llI" Town, Stel.)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />CAUSE OF DEATH (See Instructions and examples)
<br />
<br />11. PMT. ,. &IIaIJ.... ...... tIt.-- - cMMIet,'riJurM. or i:ompll~on.~ thai. di*Uy "auad Ih. dulh. DO NOT .nUlr ltmUnal O~l'Iot& :lLlch .. ~dlin: amll8t,
<br />rnplmory Inwr. or "pbicullr nlN'lhltlon without Ihowl-'I 1M et'Olog)'. 00 t,lOT A8BREVlAT~_ Enllu only on. (:IUM on .. line. Add addltionalllnellf MC....ry.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />IMMEDIATE CAUSE (Flnel
<br />dl..a.. or condition ....ultlng III)
<br />In doathl
<br />
<br />17 )\l...Vl /'11 ~;1 " ~
<br />
<br />I APPROXIMATE INTERVAL
<br />I
<br />I on.et to delldh
<br />
<br />~ I tv/-
<br />
<br />Sequ.ntl.nyn.t candltlan., II b)
<br />Iny, I..dlng I<> the c.u.on.ted
<br />on IIn. a.
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />L.Ur'! q C tlyt
<br />
<br />DUE TO, OR AS A CONSecrlJENCE OF:
<br />
<br />u......
<br />
<br />: on.et to death
<br />
<br />: '3 ~(' \4\-,
<br />
<br />l!nter the UNDERL YlNG CAUSE cj
<br />(dl..... or Injury th.' Inltlat.d
<br />th. o.onle re..IUng In d..thl DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />: on..t to death
<br />I
<br />I
<br />I
<br />I
<br />
<br />d)
<br />
<br />I onset to death
<br />I
<br />I
<br />I
<br />I
<br />
<br />lB. PART II. OTHER SIGNIFICANT CONDITlONS-CandIUan. cantribuUng ta 'h. d.eth but not reeultlng In the und.rlylng CI." gl..n In PART l
<br />
<br />C-DPD
<br />
<br />19. WAS MEDICAL EXAIIIINER
<br />OR CORONER CONTACTED?
<br />~ES 0 NO
<br />
<br />II::
<br />W
<br />ii:
<br />ffi
<br />u
<br />j
<br />~
<br />i5.
<br />~
<br />u
<br />dl
<br />~
<br />
<br />20. IF FEMALE:
<br />o Not pregnon' within pnt Y.lr
<br />o Pregn.nt at tlm. af d.ath
<br />o Not prellnenl, but pregnant within 42 day. af death
<br />o Nat p"gn.n~ but p..gnonl43 d.y. to 1 ye.. befare doath
<br />OUnknawn If pregn.nt within th. pnt yoar
<br />
<br />210. MANNER OF DEATH
<br />S Naturll 0 Homlcld.
<br />o Accld.nt 0 P.ndlng In.nllgatlon
<br />o Sulcldo 0 Could nat be dot.nntn.d
<br />
<br />21b.IF TRANSPORTATION INJURY
<br />o Drl..rlOp.i'etor
<br />o p....nger
<br />o podntrlan
<br />o Other (Specify)
<br />
<br />210. WAS AN AUTO~~ PERFORMED?
<br />
<br />DYES ANO
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />
<br />DYES [!Jl.o
<br />
<br />221. DATE OF INJURY (Ma., DIY, Yr.1
<br />
<br />T22~~I~~~0~I~J.~RYJ22~.PLA~~0~ :N~~R~~A~h_ome, form, .tre.~ flCtory, omc. building. con.trucUan .11e, .tc. (Specify)
<br />
<br />22d.INJURY AT WORK~ 220. DESCRlBl! HOW INJURY OCCURRED
<br />DYES ONO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />p
<br />\\
<br />
<br />231. DATE OF DEATH (Ma., DIY, Yr.)
<br />!'~ ~ ?Q ?nnA !'~~
<br />
<br />li~ '''iOft-ll:~-'''' "I I =O;,~:m A . m U ~ ~ ~ ~"""=-...,.." "I - - ~",m_ m
<br />
<br />
<br />.. ~,,~o 23d. To t'!.~t 01 m knowl.dg., death occurnod at the um., dlle Ind ploc. 8 !!:j ~ 0 240. On the be.l. of .x.mlnlllon andlar In.nll",Uon, In my aplnlon death occurnod
<br />~! Ind ~~.and Tltl.) ~ I ~ at the Um., dlte .nd pllc, .nd due to the couu(.) .toted. (Slgneture .nd TlU')
<br />
<br />
<br />
<br />
<br />2B.~TOBAccb..t(SE CONTRleUf TO THE DEATH? IHa. HAS ORGAN OR nSSUE'pONATlON BEEN CONSIDERED? IHb. WAS CONSENT GRANTED?
<br />J.lIl YES 0 NO 0 PROBABLY 0 UNKNOWN 0 YES J&l NO Not Appncabl.1f HI I. NO 0 YES litNO
<br />
<br />27. NArilE, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Prlnt)
<br />
<br />Travis Hageman, M.D., 729 N. Custer 'Ave.. Grand Island. Nebr~~k~ ~RRn1
<br />
<br />2Ba. REGISTRAR'S SIGNATURE M... L 11..1. ~:., 2ab. DANOV BY RiGli068(Mo.. Day, Yr.)
<br />
<br />
<br />V
<br />
<br />240, OATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
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