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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTJ::J.,!ff(J~i1'rW1'l1IW SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBIfA5k!J~. . FffMEIWr.....OF HEAL TH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FCffl'K{r2A).. ~~QRb5'i, . ;. ,
<br />
<br />DATE OF ISSUANCE ~1!J.~~
<br />
<br />S1ANL~;J;OQPfiR: " .. , .
<br />AssIst ~T$f.IiEGI~~k~
<br />aEPAR lWio.F~EliL rH AisJD..
<br />LINCOLN, NEBRASKA HOf1:4.N $ERVICI;$ : ,. :' J;: ,'.
<br />".. '..I~::.~..... ~ ,....;II~.r... c--,) .
<br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUMAN SERVrcE~',;- 1:Jifl'l,'i\:' ',':2.<\ '0-76
<br />C TI ICATE F .' ".U:3"', ,~q
<br />~,su or (lEATH. o.,Oey,Yr.)
<br />
<br />.'
<br />
<br />STATE OF NEBRASKA
<br />
<br />MAR 0 6 2009
<br />
<br />200903746
<br />
<br />
<br />1.0liceOeNT'S-NANlIi (FI"'!,
<br />
<br />Loo!,
<br />
<br />Suffix.
<br />
<br />Nllddle,
<br />
<br />(Y",.)
<br />
<br />HOURS 'NlINS.
<br />
<br />Female February 27, 2009
<br />5.. AGE-LooI Blrthdey 5b. UNDER 1 VEAR 5C. UNDER 1 DAV 6. DATE Of BIRTH (Mo., Dey. Vr.)
<br />
<br />Ann Schroder
<br />4. CITY AND STATE OR TERRITORV, OR FOREIGN COUNTRV OF BIRTH
<br />
<br />MOS. DAVS
<br />
<br />Grand Island, Nebraska
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />73
<br />
<br />S.. PLACE OF DEATH
<br />lliliI!lIAl.:. 0 Inpellenl
<br />o ERlOutpellenl
<br />ODOA
<br />
<br />~ IXI Nu",'ng HomelL TC
<br />o Decedenr. Hom.
<br />o Oth.r(Sp.clly)
<br />
<br />~
<br />....
<br />~
<br />1:5
<br />
<br />508-38-6421
<br />
<br />Sb. FACiliTY-NAME (II not In.lllullon,gl.. .tr..1 end number)
<br />
<br />St. Francis Memorial Health Center LTC
<br />
<br />6c. CITY OR TOWN OF DEATH ('nc'ud. 2:lp Cod..
<br />Grand Island 68803
<br />
<br />ad. COUNTY OF DEATH
<br />
<br />Se. RESIDENCE-8TATE
<br />
<br />tb. COUNTY
<br />
<br />
<br />If. 2:lP CODE
<br />
<br />z
<br />::)
<br />II..
<br />~
<br />a:
<br />I;:
<br />'I:
<br />..
<br />~
<br />l
<br />ii
<br />e
<br />o
<br />u
<br />..
<br />III
<br />o
<br />I-
<br />
<br />Nebraska
<br />td. STREET AND NUMBER
<br />112 Wainwright
<br />
<br />Hall
<br />
<br />December 25, 1935
<br />
<br />o Ho'plce Feclllly
<br />
<br />10.. MARITAL STATUS AT TIME OF DEATH iii Menied 0 Never Menied lOb. NAME OF SPOUSE (Flr.1, Middle, La.I, Suffix) II wile, give m.lden neme.
<br />
<br />
<br />o Mem.d, bul .epereled 0 WIdowed 0 Divorced 0 Unknown
<br />
<br />68801
<br />
<br />9g. INSIDE CITY LIMITS
<br />~ Ve. 0 No
<br />
<br />
<br />Louis
<br />
<br />Rauert
<br />
<br />U, MOTHER'$-NAME (FI"'t,
<br />Hanson
<br />
<br />Middle,
<br />
<br />11. FATHER'S-NAME IFi"'!,
<br />
<br />Middle,
<br />
<br />Lesl.
<br />
<br />sumo)
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dele. ohervlc.IIV...
<br />
<br />(V,,, No, or Unk.) No
<br />
<br />15. METHOD OF DISPOSITION
<br />IiIUuria' 0 DOnlllio-'
<br />
<br />o C,.matlon 0 Entombment
<br />OR,,"ovel OOl~.rt''''''1y1
<br />
<br />CITYfTOWN
<br />
<br />15b. LICliNSE NO.
<br />
<br />/0397
<br />
<br />Grand Island
<br />
<br />Westlawn Memorial Park Cemetery
<br />
<br />17.. FUNERAl HOME NAME AND MAILING ADDRESS (SI",.I, City or Town, S'-Ie)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />
<br />CAUSE OF DEATH See Instructions and exam les
<br />
<br />11. PART I. Enter the chain DllllftHtu _ dl'C1"..e., Inj1ulell, Dr complication... that dlr1lC;tly lUIIu..d th* ddtl"l. DO NOT enter tennlnal eventl.uch II cII'CIIIC arrest.
<br />re.plrlltory BrnBt. or ventricular flbril..t1on without .howlng th. .t10Iugy. DO NOT ABBREVIATE. !ntlr onl)' on. c:au.. on .. line. AcId addltloMllln.. tf niK..N1ry.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl....e or condlllon ",.ulllng .)
<br />In d..lhl
<br />
<br />Sequenllally 11.1 condition., II bl
<br />any, leading to the C8u..n.ted
<br />onlin....
<br />
<br />DUE TO, OR AS A CONSliQUeNCE OF:
<br />
<br />Enlerth. UNDERL VING CAUSE C)
<br />(dl..... or Injury Ih.1 Inlll.ted
<br />Ihe even'- ",.ulllng In de.th) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />
<br />d)
<br />
<br />16. PART II. OTHER SIGNIFICANT CONDITIONS.condlllon. contrlbullng 10 the d.elh bul not re.ulting In Ihe unde~ylng ceu.e given In PART I.
<br />"'"
<br />
<br />0:=
<br />W
<br />ii:
<br />~
<br />w
<br />u
<br />;.:.
<br />.Q
<br />
<br />~
<br />ii
<br />e
<br />o
<br />u
<br />~
<br />{3.
<br />
<br />
<br />~O. IF FEMALE:
<br />~ot p...gnant within p..t year
<br />o pregn.nl .1 lime of deelh
<br />o Not pr.gn.nl, bUI p"'gnanl within 4~ d.y. 01 deeth
<br />o Nol pregn.nl, bul pregn.nl 43 d.y. 10 1 y.ar b.lore d..lh
<br />OUnknown If pr.gn.nl within Ihe p..1 ye.r
<br />
<br />21a. MANNER OF DEAT
<br />~ural 0 Homicide
<br />o Accld.nl 0 P.ndlnglnve.tigallon
<br />o Suicide 0 Could not be detennlned
<br />
<br />~lb.IF TRANSPORTATION INJURY
<br />o D~verIOp.relor
<br />o P....nger
<br />o Pedest~.n
<br />o Olher (Specify)
<br />
<br />22d.INJURV AT WORK?
<br />o YES ~O
<br />
<br />
<br />M.ld.n Sum.m.)
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />HUSband
<br />
<br />16c. DATE (Mo., D.y, Vr.)
<br />
<br />March 3, 2009
<br />
<br />STATE
<br />
<br />Nebraska
<br />17b. 2:lp Cod.
<br />68801
<br />
<br />
<br />: onset to death
<br />I
<br />I
<br />I
<br />I
<br />
<br />I on..t to death
<br />,
<br />I
<br />I
<br />I
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />o VES !it'NO
<br />
<br />21c. WAS AN AUTOPSY PERFORMeD?
<br />DYES Ij;fl(o
<br />
<br />21d. WERE AUTOPSV FINDINGS AVAILABLE
<br />TO CONlPLETe CAUSE OF DEATH?
<br />o YES ~O
<br />
<br />~~. DATE OF INJURV (Mo.. D.y, Vr.)
<br />
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, fann, .treet, factory, office building, con.truction elte, etc. (Specify)
<br />
<br />~~I. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />CITYfTOWN
<br />
<br />
<br />~3e. DATIi OF DEATH (Mo., Dey, Yr.)
<br />
<br />February 27, 2009
<br />
<br />~3b. DATE SIGNED (Mo., D.y, Yr..
<br />March 2, 2009
<br />
<br />~3c. TIME OF DEATH
<br />
<br />Z>
<br />,.,~w
<br />.0 2~
<br />a: III 0
<br />Ji~I:>
<br />Doll. 0( ..J
<br />~ ~~ ~
<br />UWZ
<br />"'Z:J
<br />.0 00
<br />~ rr.U
<br />0..
<br />vo
<br />
<br />N.. DATE SIGNED (Mo.. D.y, Yr.)
<br />
<br />No. PRONOUNCED DEAD (Mo.. Day, Yr.) lI4d. TIME PRONOUNCED DEAD
<br />
<br />rn
<br />
<br />2:43 P.rn
<br />
<br />m
<br />
<br />~4e. On the b.sia at ..amln.t1on .nd/or Invesllg.tlon. In my opinion d.ath occurred
<br />al the lime, dal. .nd pl.c. .nd due 10 the c.u..(s) .teled. (Slgn.lure end Till.)
<br />
<br />~3d. To the besl 01 my knowledge. de.lh occurr.d al Ih. 11m., d.t. .nd pl'c,
<br />. to Ih'~~ .'-t.d. (Slgnelur. end TItle)
<br />
<br />\eo~ill,
<br />
<br />~8e. HAS ORGAN OR TISSUE og,AnON BEEN CONSIDERED?
<br />o ViiS lB"N0
<br />
<br />o PROBABLY 0 UNKNOWN
<br />
<br />~7. NAME, 7lTLE AND ADDRESS OF CERTIFIER (PHVSICIAN, CORONER'S PHVSICIAN OR COUNTY ATTORNEY) (Type or P~nl)
<br />Ryan Crouch, D.O., 800 Alpha st., Grand Island, Nebraska
<br />
<br />~8a. REGISTRAR'S SIGNATURE
<br />
<br />
<br />STATE
<br />
<br />2:lP CODE
<br />
<br />24b. TIME OF DEATH
<br />
<br />~6b. WAS CONSENT GRANTED?
<br />Nol Applicable It ~6. is NO 0 VES ~
<br />
<br />~8b. DATE FILED '1J~TRAR.f02tr09r.)
<br />
<br />68803
<br />
<br />p
<br />
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