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<br />STATE OF NEBRASKA
<br />
<br />- WH%N THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL TH Atyj,J.jj.4!Ml.W SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COpy OF THE ORiGINAL RECORD ON FILE WITH THE NEBRASI>~,fYE1Y~.fl.T~~~n.q~ HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V"IjL1~Et~~Fi.~f!j-'i".i . · I
<br />
<br />DATE OF ISSUANCE ~'<~1f~,
<br />STANLEY S. COOfPER" ......', ·
<br />AS.. ~tSrAN.V...C:6 6~j-e..,.~. ..E...G...15. ~.RA'R...~. "
<br />Dt;PAR':[M8ii1Jrl$ .t#if.~!.,H AIY1?' ;':
<br />HU~M. SE:RVICES. .: ,:;' "I
<br />(:,). \ ~ ,. : ( "" , '" I''''.) t ."'/
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICEg'. .,... . ..'~C' li~" c' <'\_ ~..." ~;; L._
<br />CER DEATH >,......\1 ,'IZ161'7'\).\..:"
<br />1. DECEDENrS-NAMI: (Flret, MI~~lo. Loot, Suffix) 2. SEX a. QIl're ,PF.D~!H.lMo.,D~.)
<br />
<br />MAR 1 8 2009
<br />
<br />200902173
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />
<br />James Robert Schloer
<br />4. CITY AND STATE OR TERRITORY, OR FORI:IGN COUNTRY OF BIRTH
<br />
<br />Male
<br />
<br />Februa 15, 2009
<br />
<br />So. AGE-Loat Blrlh~1Ij/ Sb. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />lYre.)
<br />
<br />MOS. DAYS
<br />
<br />HOURS MINS.
<br />
<br />Minot, North Dakota
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />70
<br />
<br />July 19,1938
<br />
<br />501-36-6613
<br />
<br />ea. PLACE OF DEATH
<br />1lQWIAL.; !&Ilnpatlont
<br />o ERlOutpatlont
<br />DlIOA
<br />
<br />QJ~ 0 Nurelng HomelL TC
<br />o Deco~onfo Home
<br />CJGhr(8pell~)
<br />
<br />o Hospice Facility
<br />
<br />D::
<br />e
<br />.U
<br />W
<br />.-.
<br />5
<br />..J
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<br />w
<br />Z
<br />::J
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<br />a:
<br />II:
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<br />
<br />'is.
<br />g
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<br />...
<br />lD
<br />o
<br />I-
<br />
<br />8b. FACIUTY.NAME (If not Inatltutlon, give etreet and number)
<br />
<br />,. BryanLGH Medical Center East
<br />
<br />8c. CITY OR TOWN OF DEATH (Inclu~o Zip CodO)
<br />Lincoln 68506
<br />Ba. RESIDENCE-STATE
<br />
<br />8~. COUNTY OF DEATH
<br />
<br />Nebraska
<br />8d. STREET AND NUMBER
<br />
<br />Hall
<br />
<br />
<br />9f. ZIP CODE
<br />
<br />Bb. COUNTY
<br />
<br />224 E. 21 st St
<br />
<br />68801
<br />
<br />Bg. INSIDE CITY LIMITS
<br />IKI y"" 0 No
<br />
<br />lOa. MARITAL STATUS AT TIME OF DEATH iii Merried 0 Never Marrie~ lOb. NAME OF SPOUSI: (FI...I, MI~~le. Leet, Suffix) Ifwlfe, give mal~on name.
<br />
<br />
<br />D Marrie~, but aeparalO~ 0 W1~owed 0 Divorced D Unknown
<br />
<br />
<br />11. FATHER'S-NAME (FI...I, MI~~la, Lot. Suffix)
<br />
<br />MI~~la, Malden Surname)
<br />
<br />Robert A Schloer
<br />
<br />14b. RELATIONSHIP TO DECEDI:NT
<br />
<br />(Yea, No, or Unk.) Yes
<br />1S. METHOD OF DISPOSITION
<br />[ilBurta' OOonlllon
<br />DC..mlltlon DEntombment
<br />OR:lllrnova, Dot...r'(S~!;tfy.
<br />
<br />CITYITOWN
<br />
<br />Wife
<br />
<br />lSc. DATE (Mo., Day, Yr.)
<br />
<br />Februa 19,2009
<br />
<br />STATE
<br />
<br />
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streat, City or Town, SIIIO)
<br />
<br />Grand Island
<br />
<br />NebraSka
<br />17b. Zip Code
<br />
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />
<br />CAUSE OF DEATH See Instructions and exam les
<br />11_ PA~T I, En.... t.... ~~ - d......., l"ljUI'it., or (;t::Jmpllcilltlon.~ that dlntclly CIIuMd tht: death. DO NOT enter tennl~1 rJants suer. .. c:afdtac. lImt~
<br />....plmory arrest, 01' wl'ltricula.. nbr1ls.don wltlwut showlna ,.. etfology. DO NOT ABBRIiVlA.'M.. EnIH anlY ant: tlu.. 0" a 11M. Add .ddttllHUllll,., IT noe....ry.
<br />
<br />68801
<br />
<br />IMMEDIATE CAUSE (Final
<br />.~'!'.r:i'ffifr,~~n~I\IOn reeulllng
<br />
<br />a)
<br />
<br />J':.-..,kc-~'\)"",
<br />
<br />I APPROXIMATE INTERVAL
<br />I
<br />c'}~to~eallt
<br />
<br />;4;;f{Y;;:2:.'0l~ ~'.t
<br />
<br />Enter the UNDERLYING CAUSE c)
<br />(~Iaeaae or Injury that Inltlate~
<br />the eVllnts resulting In death)
<br />LAST
<br />
<br />
<br />,o"\(L
<br />
<br />ss~c~
<br />
<br />: on.et to d..th
<br />
<br />: Zdl'\. J
<br />
<br />Sequentially 1I0t con~ltl"na. If b)
<br />_ny, leldlng to the Cause listed
<br />on line a.
<br />
<br />vA. :-K~~
<br />
<br />: onaet to ~eath
<br />I
<br />: ye....rs
<br />
<br />d)
<br />~,'%G'MT,a.OTHER SIGNIFlCANTCONDI110NS-con~llIona conl~butlng to tha daath but not reaultlng In tha underlying cause given In PART I.
<br />
<br />I onset to death
<br />I
<br />,
<br />,
<br />I
<br />
<br />CoPD
<br />
<br />~c..... ~ re v..t>.
<br />
<br />J: " {v-v-L-
<br />
<br />11. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED7
<br />D YES ~O
<br />
<br />lI::
<br />w
<br />i:i:
<br />i=
<br />0:
<br />W
<br />U
<br />~
<br />~
<br />'is.
<br />E
<br />8
<br />.AL
<br />{!.
<br />
<br />20. IF FEMALI::
<br />D Not pragnant wlthln past year
<br />o Pregnant at time of death
<br />o Not pregnant, but pregnant within 42 ~ays of death
<br />o Not pragnant. but pregnant 43 ~aya to 1 year before ~eath
<br />D Unknown II p';'gnant within the past year
<br />
<br />21a. MANNER OF DEATH
<br />~atu"l 0 Homlcl~e
<br />o Accident 0 Pen~lng Inveatlgatlon
<br />o 5ulcl~e 0 Coul~ not be ~atarmlne~
<br />
<br />21b. IF TRANSPORTATION INJURY
<br />D D~vor/Ope..lor
<br />o Pusenger
<br />o Pe~aatrian
<br />o Other (Specify)
<br />
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />DYES )fNb
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES ONO
<br />
<br />22a. DATE OF INJURY (Mo.. Day, Yr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY-At home. farm, atrest, factory, oIIIce bUII~lng. conatructlon alte, ate. (Specify)
<br />
<br />22d.IIliJlJI(yA T WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES ONO
<br />
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYrrOWN
<br />
<br />STATl! '
<br />
<br />Z1' CODE
<br />
<br />
<br />23a. DATE OF DEATH (Mo.. Day. Yr.)
<br />
<br />24a. DATI: SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />~ placa
<br />
<br />,..~i'ii
<br />.c 2~
<br />illlO
<br />]i?i:I=>
<br />a.D..<(..J
<br />~ ~~ ~
<br />"'wz
<br />1: z:::.
<br />o~O
<br />I- O~
<br />00
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo.. Day, Yr.) 24<1. TIME PRONOUNCED DEAD
<br />
<br />m
<br />
<br />248. On the basi. of examination and/or lnv,etlgltlon, In my opinion d..th occulTed
<br />.t the lime. ~ale an~ placa .n~ ~ua to the cauae(a) a_. (Signature and TIlle)
<br />
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable II 28a la NO 0 YES NO
<br />
<br />27. NAME. TITLE AND ADDRESS OF CI:RTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />
<br />Dr. Ryan Whitney.
<br />28a. REGISTRAR'S SIGNATURE
<br />
<br />1600 S. 48th Ste. 600 Lincoln. NE 68510
<br />
<br />LINCOLN. LANCASTER CO. HEALTH ~T. ,
<br />......"... .....'"....( tf.
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />).. FEB 2 6 2009
<br />
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