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STATE OF NEBRASKA
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<br />«. WMEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH~.fi(1Vb F#~A/U $11;R,VICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ~PA, - , M~N~' Q~',Ii~EALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR•~WIT~'L R~C ~~ ' ~
<br />DATE OF ISSUANCE ~j , ,
<br />STANLEY S~Q~S '"r ~,,
<br />Nou 2 0 X009 2 0 0 9 0 9 9 0 2 ASSj~TAN 1~2A1~ .~
<br />DEPARTMENT" Old tf~,~Ctk~M ~i(Ul~ i ,~
<br />LINCOLN, NEBRASKA HUMAM SEG~VICE~ +" , ~, .~ ~-,' ,.. '
<br />STATE OF NEBRASKA-DEPARTMEN70FH~ALTM AND HUMAN SERVICES FINANCEANI7SUfPp~".~,, .~•~~ ^ O
<br />CERTIFICATE OF DEATH t( 1~ L.~
<br /> 1. OECEPENT'3•NAME (First, ~ Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br /> Merlyn Wayne Schmidt Male October 21,
<br />2009
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Leal Birthday 5h. UNDER 1 YEAR 5c. UNDER 1 DAV _
<br />8. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAVE HOURS MIN$.
<br /> Riverton, Nebraska 86 March 12, 1923
<br /> 7. SOCIAL SECURITY NUMBER 89. PLACE OF DEATH
<br /> 723-03-7102 HOSPITAL: ^ Inpatient 4LJF8 ~ NursingHOme/LTC C7HOSpiceFaclllty
<br /> Bb. FACILITY•NAME (If net Institution, glue street and number)
<br />_ _
<br />q ER/Outpatient ^ Aecident'i Home
<br /> Tiffany Square Care Center
<br /> f^ ppq ^ahar(speclry)
<br /> Bo.CITVORTOWNOFDEATH pncludeZipCade) ~ Bd.000NTYOFDEATH
<br /> Grand Island 68$03 Hall
<br /> Sa. RESIDENCE-STATE gb. COUNTY gc. CITY OR TOWN
<br /> Nebraska
<br />_ _ kIall Cairo
<br />- gd.STREETANDNUMBER 9e. APT. NO 9f. ZIP CODE gq.INSIDECITYLIMITS
<br /> _ 607 S. Thebe _ _ _ 6gg24 ~7 vl:s '^ No
<br /> tOa.MARITAL STATUS AT TIME OF DEATH ^ Marrletl ^ Never Married 10h. NAME OF SPOUSE (FIr61, Middle, Laet, Suffix) If wife, give maiden name,
<br /> ^ Married, but separated ~I Widowed ^ Divorced Q Unknown
<br /> t t. FATHER'S-NAME (First, Midtlle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br />
<br />s William Schmidt
<br />-.._...,--- .-- -- Lydia Goebel
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<br />13. EVER IN U.S. ARMED FORCE37 Glve datesoleervice if yes.
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<br />14e.INFORMANT•NAME _...._._
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<br />14h. RELATIONSHIP TO DECEDENT
<br /> (Yea, nd, Brunk.) No _ _ Connie Stromer Dau hter
<br />- _ _-._,
<br />15. METHOD OF DISPOSITION i8a. E BALMER•SIGNA UR
<br />i8b. LICENSE N0. 16c. DATE (MV., Day, Yr.)
<br />^°}' _,/•~
<br />~Burlal ^Donation ~,[,({ ~T_, _. /3otg
<br />October 2_2009
<br /> ^Crematlpn ^Entomhment 16d.CEMETE ,CREMATORY OR ER LOCATION CITYITOWN STATE
<br /> ^ Removal U Other (SpBClfy)
<br />'~''F Mt. Pleasant Cemetery Cairo, Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty Or Town, State) ~. ~ 17h. Zip Code
<br /> Apfel Funeral Home, 1123 West Second, Grand Island, Nebraska 68801
<br />;~ 18. PART 1. Enter the GhNln of events-•dleeaaea, in)Wlee, br COmpIlCatltlna--that directly caused ins death. Dq NOT enter terminal events such ae CardldC arrest, I APPROXIMATE INTERVAL
<br /> respiratory arrest, or ventricular ribrillation wilh0ut ahvwing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary, I
<br />. IMMEDIATE CAUSE: ,.,„ ._,._.,I~..ds~~.,. _ ..._,
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<br />n IMMEDIATECAUBE(Flnel
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<br />dlaeeaearcondtlltlnraeultlng VETO, RASACONSEQUENCEOF: ~ I anaettodealh
<br />In death) ~.~-_,, ~,p ~ I
<br />SaquaMlellytlatcandltlane,lt (h) V !/ / T'~ ~~ ~~" ~ ~~
<br /> any, Mdingtotheceuw listed pUE TD
<br />OR AS A CON ENCE OF: I
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<br /> Erder dte U NDERLYING CAUSE
<br /> (dlaesas ar ln)urythat initiated (c) I
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<br /> theaventa reeu8ing In death) DUE TO,OR A3ACONSEQUENCE OF: I onset to death
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<br /> 18. PART ILOTHER SIpNIFICANT CONDITIONS-C
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<br />dlllone contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
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<br /> 20. IF FEMALE: 21 e.MP~INEROFDEATH 21 b. IFTRAN5PORTATIONINJURY 21c.WASANAUTOPSYPERFORMED7
<br /> ^ Not pregnant wlthln peat year Natural ^ Homicide ^ Driver/Operator
<br />^YE5 ~JO
<br /> ^Paasenger
<br />^ Pregnant et time of death ^ ACCldenl^ Pending InvOaugation __
<br /> ^ Not pregnant, but pregnant wlthln 42 days cl death ^ Pedestrian 21d. WERE AUTOPSY FINDIN03 AVAILABLE TO
<br />Q Sulclde ^ Cduld not pe determined
<br /> ^ Other (Specify)
<br />^ Nat pregnant, but pregnant 43 days 101 year before death COMPLETE CAUSE OF9 EATH7
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<br />^ Unknown If pregnant wlthln the pest year ^ YE3 rrv0
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<br />22a. DATE OF INJURY (Mo., Day, Yr.) 22h. TIME OF INJURY 22c. PLACE OF INJURY-At hams, term, street, factory, office building, consiructlon ells, etc. (Spedfy)
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<br />22d.INJURY AT WORK? 22a. DESCRIBE HOW INJl1RY OCCURRED
<br /> ^ YES ^ NO
<br /> .~4Lj,(~TIQNj,)F.!NJURY • STREET $ NUMBEq, APT. N0. CITYROWN ~ _ STAiE ~.. ZIP CODE
<br /> 23a. DATE OF DEATH Mo., Day Yr.) 24a. DATE SIGNED (Md., Day, Yr.) 24b.TIME OF DEATHF~
<br />~.~ October 2i, 2b09 y,~ Z m
<br /> g=T 23b. TES NED 11Mc., Day, YrJ 23c.TIME OP DEATH ~~
<br />24c.PRONOUNCED DEAD (Mo., Dey,Yr.) 24d. TIMEPRONOUNCED DEAD
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<br />~a= ab r Zl, 2009 12:35 am
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<br />g ~ 23d. To st of my knowledge, death occ rred at the time, dale end place ~ ~ ~ 24e. Dn the basis of examinatlvn andlvr Investlgatlon, In my opinion death occurred et
<br />e - ~ ~ e(e) eta Sign ure and Title j • ~
<br />the lime, data and place and due to the causels) stated. (Signature entl Title )'I
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<br />- 25. DI TOGA OUSEGONTRIBUTETOTHEDEAT 26a.HASORGANORTISSUEDONATIONBEENCONSIDERED? 28b.WA5CON5ENTGRANTED7
<br />`•` ^ YE3 _ ^ NO ^ PROBABLY UNKNOWN ^YE5 ~J ND ___ Not Applicable II 28a le NO ^ YES NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,CpRONER'3 PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br /> John Wagoner M.D. 800 N. Al ha Ave., Grand Island NE 68803
<br /> 28e. REGISTRAR'S SIGNATURE
<br />~ 28b, DATE FILED BY REGISTRAR (Mo., Day, YL)
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<br />HHS-61 11!03 (55081)
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