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STATE OF NEBRASKA
<br />,- l~W-IEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AN~9RAl t~ I~VICES, TT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA,6ii~EA T~N(E~fV~ p' IWa~A'LTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH I$ THE LEGAL DEPOSITORY FOR VITA.. DS.. , • ' ~~ r , a 9
<br />~- !~ d
<br />DATE OF ISSUANCE '
<br />r 8 ~r O V a ~ 8 ~ ~ ~i STA/~L~k` ~. CO~PEI~~ ... ., ,
<br />~~ 1 a ~oo~ ASS,F~St,~IVT S ~t • ,I5~"~~ .• +"
<br />DEPARIY~1El~lI~~E#I-I~AN~FJ • :"'
<br />LINCOLN, NEBRASKA HUNlAI1~~41~ZV'IG~.~'
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<br />n STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES c~~ p ~~ y~• ~ ~~ • '
<br />t 1 CERTIFICATE OF DEATH
<br /> 7. DECEDENTa~dAME (Pint, Middle, Last SuRlx) 2 SEX ATE , PEA )M¢.,D+y, .)
<br /> Laurent Patrick Schafer Male ~ September 2$, 2009
<br /> A CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE•Last Birthday 5b. UNDER 1 YEAR tk. UNDER 1 OAY 6. DATE QF 91RTN (Mo., Dry, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MWa.
<br /> O'Connor, Nebraska 77 June 3, 1932
<br /> 7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br /> 507-36^7294 uncwr~y; ^ Inpaaem 4StjE8: ®Nuning Hamsll.TC ^ Hasplca Fadlily
<br />U eb. FACILnY-NAME (H not Inratuaon, give greet and number) ~ ~ ^ ERlOrdpaaant ^ Oacedanra Home
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<br />Wedgewood Care Center
<br />^ °OH ^ oalar(Speciry)
<br /> . tasY OR TDYYN OP DFATN'(Ineuea ap Coaa) "~ COBR'IY Df DEATH - .
<br /> Grand Island 88803 Hsll
<br /> ea. RESIDENCESTATE Ab. COUNTY ik. CITY pR TOWN
<br /> Nebraska Hall Grand Island
<br />.~ 8d. STREET AND NUMBER 9e. APT, NO. 9f. LP CODE >)4• INSIDE CnY LIMITS
<br /> 211 E. 20th B8801 ®Ya ^ No
<br /> 18a. MARITAL STATUS AT TIME DF DEATH ®Matried ^ Nrvet Nettled 186. NAME OF SPOUSE (Pint, Middle, Lest, Suffix) g wHs, ghro mNden dame.
<br /> ^ Nettled, but separated ^ Widowed ^ Dlwnced ^ Unknown Virginia A Wissbaum
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<br />E 11. FATHER'S-NAME (First Middle, Last Sedllx) 1Y. MOTHER'S-NAME (Flrat Middle, Maiden 8umams)
<br />0
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<br />Wt:rman D Sotlafer
<br />Aileen F O'Connor
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<br />m 17. EVER IN U.S. ARMED FORCES? Giw dates of sarWca K Yes. 14a. INFORMANT-NAME 144. RELATIONSHIP TO DECEDENT
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<br />(vae, No, a umc.) yeg p2/11/1952-01!03!1956
<br />Vi inia A Schafer
<br />Wife
<br /> 15. METHOD OF DISPOSITION 18a. EM ER-6IGNATURE .~'~ '~ 18b. LICENSE NO. 7tk. DATE (Mo., Dey, Yr.)
<br /> ®e"n" p°°'""'n Cr.~~~t-..J ~L) ~ c~ October 2, 2009
<br /> ~Qrame[ion [~emomren.m
<br /> ^Ramv~n ^OiharlapKlyl 71W. CEMETERY, CREMATORY OR OTHER LOCATION CYTY/TOWN aTATE
<br /> Weatlawn Memprial Park Cemetery Grand Island Nebraska
<br /> 77a. FUNERAL HOME NAME AND MAILING ADDRESS (Strwt City or Tdwn, Stah) 17b. Zip Code
<br /> Curran Funeral Chapel, 3005 S. Locust 5t., Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH See In$tructions and examples
<br /> 1a. PART i. Erd.r ttw eeem a areab _ dieaaaae, YQarMe, a eamplkaaona-slut dpaa4y vtuaed dw degh, t1O NOT enpr terminN evwna each r wrdMw aural, ; APPROXIMATE INTERVAL
<br /> u•Plbatlr MnM. yr vnddcmar iPotale¢an wuhval rhawina er MMIOYP. tlo Nor AetlREVIA7E. Ems. any atw e.w an ~ ens, Add addlavtrl utr p neeYrYy.
<br /> IMMP-bIATE CAUSE: : onwt to death
<br /> IMMEDIATE CAUSE (Final
<br /> dlawes or candlaan naultlng a)
<br /> in ttaaat)
<br /> _ DUE TO, OR AS A CONSEtlUE 13 OF: ..._ , j 9rraet
<br /> Sequenaally Ilst conditlans, g b)
<br /> arty, haling to are uux listed
<br /> on line a. DUE TD, OR AB A GDNBEDUENGE OF: ~ onset to loath
<br /> ErdM the UNDERLYING CAUSE ¢)
<br /> (dlaeaee or injury gut Initlahd
<br />lM ewnfe rseuldng In deatlt) DUE TO, OR AS A CONSEQUENCE OF: ~ onset h death
<br /> LAST
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<br /> . PART II.OTHER SIGNIFICANT CONDITIONS-Condlaons comributinq m the death but Itot rewlanp in tln underlying cause piwn in PART 1. 19. WAa MEDICAL EXAMINER
<br /> pRCOROMERGONTACTED7
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<br />~ ©YES ^ NO
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<br />W YO. IF FEMALE: 21 NER OP DEATH L Y1b. I TRANSPORTATION INJURY $7¢. WAS AN AUTO
<br />PERFORMED?
<br />P
<br />SY
<br />~ Not prognant wlthln poet year Natant ^ Hamlalde ^ pdwr/Oparatw ,
<br />~
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<br />^YES LjJ.No
<br />
<br /> ^ Pregnam at aura of lase! ^ Accidetd ^ Panding Imasagaaon ^ Passenger
<br />
<br />^ Not prrgnam, but pregnttm wlfhln 4; days of death
<br />^ Suicide ^ Could net M determined
<br />[] pedeatdatt Y1d. WERE AUTOPSY FINOINOS AVAILAaLE
<br />TO COMPLETE CAUSE OF DFJITNT
<br />a ^ Not pregnerd, but pregnant 43 days t¢ 7 year 4eroro death ^ Other ICY) ^YES ,,'Ll', Nf0
<br /> ^Unknown If ptagnam within the peat year
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<br />2Ya. DATE OF INJURY (Mo., Day, Yr.)
<br />YYb. TIME OF INJURY YYc. PLACE OFINJURY-At homy, hrrt4 street, ncttlty, eHica bullding, c¢natructlan tlh, etc. (Specgy)
<br />CCC
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<br />
<br /> 22d. INJURY AT T YYa. DFJ9GRIBE HOW INJURY OGGURRED
<br />~ ^YES NO
<br /> 2YF. LOCATION OF INJURY - STREET A NUMBER, APT, NO. CITYlTOWN STATE Lp CODE
<br /> 2sa. DATE OF DEATH (Mo., Day, Yr,) 7Aa. DATE SKlNED (Mo., Day, Yr.) Yob. TIME OF DEATH
<br /> a w S~±ptembe>: 28 , 2009 , ~ ~
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<br />ay, Yr.) Ya¢. TIME OF DEATH
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<br />2009 YAc. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />. To eta st of owlttdga, death occurred at lM tlme, date and place
<br />r 21a. On the basis of axaminaaon andlor Inwstlgetlon, In my opinion death occurred
<br /> Ip nd d !o the u a) ahhd. (Signature and Tiae) ~ ~ ? al ate tlme, doh and place and due h fM ¢auae(s) ahhd. (Slgnduro aM TW e)
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<br />\ Y5, pip TOBAC O CONTRIBUTE TO THE DEATH? Yea. HAS ORGAN OR TISSUE TION BEEN CONSIDEREDT Yeb. WAS CONSENT GRANTEDT
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<br />~s// ^YES O ~ PRtlbABLY ^ DNKNpWN ^YES NO Not AppllCable a 28a is NQ ©YES
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFlER (PHYSICAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type ar pdm)
<br /> Ryan Crouch M.D. 800 Alpha SC Grand Is and, Nebraska 68803
<br /> 28a. REGISTRAR'S SIGNATURE ~
<br />' Y06. DATE FILEb BY REOIS71tAR (Mo., thy, Yr.)
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