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' STATE OF NEBRASKA
<br />>E 7
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND NLIJtiIAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE ~lIITH TFIE NEBRASKA.Q~,~R~It1~l~F7w(~F, HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAS F~F'P~fRDI$,~ ~, " ~ .
<br />.... ~ T W .r.' ~ r
<br />Y 1 ~ R
<br />DATE OF ISSUANCE
<br />STA~VL~'Y' , CL~Q~'ER~a
<br />02/08/2010 2 010 015 ~'7 AS~I~AN~' ` a G.~~Tr~AR;,; •"~1,v
<br />DEP,Q`I~TMEND~~7'~i AA/© ::, ,.
<br />LINCOLN, NEBRASKA HUMAAl1$E~tVFCES _
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES',.,.."•, rp , "'~ TrtYt 1~0 00291
<br />CERTIFICATE OF DEATH ',,•'•.` ~~F1'i " ''' ' :: ..
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX $, (7ATE~OFDEATH (Mo., Day, Yr.)
<br /> Kath n Ann Schrad Female 'February 3, 2410
<br /> 4, CITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE • Last Birthday p. UNDER 1 YEAR 5c. UNDER 1 PAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Y~•) MOS. DAYS HOURS MINE.
<br /> Orchard, Nebraska 61 Octpber 29, 194$
<br /> 7, SOCIAL SECURITY NUMBER 5a. PLACE OF DEATH
<br /> 506-58-8252 HOSPITAL ®Inpatlem 41ltEB ^ Nursing Home/LTC ^ Hospice Facility
<br /> eb. FACILITY-NAME (H not Institution, glue street and number) ^ ERlOutpatlent ^ Decedent's Home
<br />
<br />~
<br />U Saint Francis Medical Center ^ DOA ^ Other(specify)
<br /> .'tat'fi-~l'TOWrrOF't7EA7H (Inelttde zip Coda) _ ,. _ -~_ ,._ . - - . _ ._ _._ : eGtllFrrY OP D134iib __ - _ _ _ . _
<br />o Grand Island 6$803 Hall
<br />Q 9a. RESIDENCESTATE 96. CQUNTY 9C. CITY OR TOWN
<br />w
<br />z Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER 94. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />;; 2723 Brentwood Blvd 68801 ®YES ^ No
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ®Marrlad ^ Never Marrlad 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wffe, glue maiden name
<br />!E
<br />` ^Marrlad, but separated ©Widowed ^ Divorced ^ Unknown Patrick Schrad
<br />w
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Dale Weber Irma Storm
<br />°-
<br />E 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yas. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />$ (Yes, No, or unk.) No Patrick Schrad Husband
<br />~' 15. METHOD OF pISPOSITION iBa. EMBALMERSIGNATURE 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />~ ®Burlal ^ Donation
<br />Derek Apfel
<br />1240
<br />Februa
<br />8
<br />2D10
<br /> ry
<br />,
<br /> © Cremation ©fzntombment
<br /> 15d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zip Code
<br /> Apfel Funeral Hpme, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> CAU E F DEA ee nstructlons an exam es
<br /> 19. PART 1. Enter the chain Qf events-~laeaa9s, injuries, or rompliratlona-that diroctly wuaed the death, p0 NOT eMar terminal BvaMa soon at CBrdIAC arrest, ; APPROXIMATE INTERVAL
<br /> reaplre[dry arrest, or ventdcular nbrlllatlon whhou[ showing the stloloflY• DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add addltlonal IlneA H neoeaAary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE IFIndI al PULMONARY EMBOLUS 6 HOURS
<br /> dsoayA or condltlort resulting .. .
<br /> In death) DUE 70, OR A5 A CONSEQUENCE OF: ; onset to death
<br /> SeauenNauy Itat conditions, If b) MALIGNANCY RELATED HYPERCOAGUABLE SYNDROME : 6 MONTHS
<br />~
<br /> :1arYppYO Y'N prrM.rlMld-..._.. ... .,_ . ............. .. _.,. ~,..u_~.-,~._. ..... _ _
<br />.. .. -..
<br />~' _
<br /> on nnA a. DUE TO, OR AS A CONSEQUENCE OF:
<br />; onset to death
<br /> Enter the UNDERLYING CAUSE C) NONSMALL CELL LUNG CANCER 9 MONTHS
<br /> (dlsea9a or Injury that Initiated
<br /> ens manes resulting in death) DUE TO, OR A5 A CONSEQUENCE OF: onset to death
<br /> IAST d)
<br /> 19. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions Contributing to the death but not resulting In the underlying cause given In PART 1. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTEDT
<br />ly, ^ YE3 ®NO
<br />W 0. IF FEMALE: 21 a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMEDT
<br />~ ®Not pregnant within past year ®Na[ural ^ Homldda ^ Driver/Ogeretor ^ YES ® NO
<br />~ ^ Pregnant al time of death ~ ACddant ^ Pentllnq InwatlQatlon ^ Passenger
<br /> ^ Not pregnant, but pregnant within 42 days oT death gulclde Could not be determined
<br />^ © ^ Pedettrlan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> ^ Not pregnant, but pregnant 49 days to 7 year before death ~ Other (Speoly) TO COMPLETE CAUSE OF DEATH?
<br /> ^ Unknown H pregnant wlinin tna pant year ^ YES ^ NO
<br />p'
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY•At home, farm, street, factory, office building, conatructlon alts, etc. (Specify)
<br />s
<br /> 22d. INJURY AT WORK? 22e. DESCRIBE MOW INJURY OCCURRED
<br />O
<br />~
<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br /> _ 23a.f>r4TE OF SEATW (Mo.; Day,~'rj __-- _ . - -24a. DATE $16NEB {Me.r Day, Yr.) 24batlbti: OF DEftTH- __._.. _
<br /> ~ February 3, 2010 ,~
<br />~
<br /> 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> g ~ a
<br />Z Februa 5, 2010 D4:35 PM ~
<br />a J
<br />E
<br />r
<br /> s 6 ¢ 49d. To the beat of my knowledge, death occurred at the time, dale and place y
<br />8 2 =qg, pn the bAAa of BxaminAgon And/or inveetiflation, in my opinion death occurred at
<br />... ~... :'^
<br />~ -arltl des leYll"tCant9(th araMrf."tDlgdEtar~iAief.-^^~..: ~-~ -. *}'-_
<br />~ ..._.yrya~lna, dANAnd'tfNL`f And d11iPo 11W t'.ibfaltTttAted:~i5lgnalure ins TltTe) .... -
<br /> Steven Husen, Mp ~ c
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 286. WAS CONSENT GRANTED?
<br /> ® YES ^ NO ^ PROBABLY ^ UNKNOWN ^YES ®NO Not Applicable if 28a Is NO ^ YE5 ^ NO
<br /> AM I ype or rlnt
<br /> Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE ' 28b. PATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> February 5, 2010
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