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.~ STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH ,4~V'~"FI'I.IINAM';SERVI~ES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASIG4 ¢E1~A12TM~EN,.T OF",HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 1/ITAL`REC,'ORQS
<br />~~ia
<br />DATE OF ISSUANCE ~ •~~~ -
<br />2 010 0 2 8 7 4 S~q~i~Y S. cOCaPER
<br />02/17/2010 ASSlSTAN~` $TA'T~ R~~~~ST'R;4~2' ,
<br />DEPARTMENT OF HEi4f TH .14t'VD
<br />LINCOLN, NEBRASKA HUMAIy~SF~tVICES
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<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH ANO HUMAN SERVICES • ; ~.' ~ '",' ~ ;"-., `:4 % .•~ '°` ~ ~ QQ~74
<br />CERTIFICATE OF DEATH " ~ '
<br /> 1. DECEDENTS-NAME (First, Middle, Last, Suffix- 2. SEX ~ 3:`DATE OF DEATH (Mo., Day, Yr.)
<br /> Lorna Doroth Schuster Female "February 7, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday b. UNDER 1 YEAR Se. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br /> IY-s•1 MOS. DAY5 HOURS MINE.
<br /> Bremen, Kansas 88 December 22, 1921
<br /> 7. SOCIAL SECURITY NUMBER Sa. PLACE OF DEATH
<br /> 508-68-8148 HOSPITAL ^ Inpatient OTHER ^ Nursing HomelLTC ^ Hospice Facility
<br /> 8b. FACILITY-NAME (ff not Instltutlon, glue street and number) ^ ER/Outpatlent ®Dacadent's Home
<br />
<br /> 1119 Kennedy Drive ^ DoA ^ Other (Specify)
<br />~ 8c. CITY OR TOWN OF DFr4TH pnclude Zip Code) ed. COUNTY OF DEATH
<br />a Grand Island 68803 Hall
<br /> 8a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br />? Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER 9e. APT. NO. 9F. ZIP CODE 9g. INSIDE CITY LIMITS
<br />T 1119 Kenned Drive 68803 ®ves ^ No
<br />~
<br />v 1pa. MARITAL STATUS AT TIME OF DEATH ^ Married ^ Never Married 1pb. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />m
<br />!E
<br />^ Married
<br />but separated ®Wldowad ^ Divorced ^ Unknown
<br /> ,
<br /> THER'S
<br />S '
<br /> 71. FA
<br />•NAME (First, Middle, Last,
<br />uffix) S-NAME (First, Meddle, Maiden Surname)
<br />12. MOTHER
<br />~ George Holle Louise Leseberg
<br />~• 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 14a. INFORMANT•NAME 14b. RELATIONSWIP TO DECEDENT
<br />$ (Yes, No, or unk.) No Jo Ce Dane Daughter
<br />a 15. METHOD OF DISPOSITION 18a. EMBALMER•$IGNATURE 18b. LICENSE NO. iec. PATE (Mo., Day, Yr.)
<br />~ ®Burlal ^ Donation
<br />Derek Apfel
<br />1240
<br />February 12
<br />201 D
<br /> ,
<br /> [~ Cremation ^ Entombment
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Ramaval ^ Other (Specify)
<br /> Bethlehem Lutheran Church Cemetery Bremen Kansas
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. Zip Code
<br /> Apfel Funeral Nome, 1123 W. 2nd, Grand Island, Nebraska 68801
<br /> AU E DEATH ee instructions and exam les
<br /> 7B. PARi I. Enter the chain o! events-diereses, Injudra, or compllcatlons-that directly nosed the death. DO NpT enter terminal sventg such as caMlac arrosL APPROXIMATE INTERVAL
<br /> respiratory arroat, or ventricular Tl6dlla[lOn without showing [ha etiology. DO NOT ABBREVIATE. Enrol Only one cauw On a line. Add addkional Imes If naceawry.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IIdMEDfATE CAt7g6(Fhiah-~ '-~FIa1tl/a1F~t12f611g~tl~~gC°`-" -~---..-... ..... ... . ___.. -.. _. __.., .... ...
<br /> tllwaw OY conddlOn resulting
<br /> In death) pUE TO, OR AS A CONSEDUENCE OF: onset to death
<br /> 5aquentialty Ilat conditions, If b)
<br /> any, leading t0 the cause listed
<br /> on Ilse a.
<br />DUE TO, OR A$ A CONSEQUENCE OF; ; onset to depth
<br /> Enter the UNDERLYING CAUSE ~)
<br /> (dlwasa or Injury that inltiatetl
<br /> the events resulting In death) pUE TO, OR A$ A CONSEQUENCE OF: onset to death
<br /> LASr d)
<br /> 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resalting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />~ ®YES ^ NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY Rtc. WAS AN AUTOPSY PERFORMED?
<br />~ ^ Not pregnant within past year ®Natural ©Homldida ^ DdverlOperetor © yE$ ® NO
<br />U ^ Pregnant at time of tleatn ©Accident ^ Pentlinq Investlpatlon ^ Paetanper
<br />7. ^ Not pregnant, but pregnant wlthln 4Z days of death gulclda Could not ba determined
<br />^ ^ ^ Pedestrian 27d. WERE AUTOPSY FINDINGS AVAILABLE
<br />a
<br />^ Not propnant, but pregnant 49 days to 1 year twfore death
<br />~ Other (Specify) TO COMPLETE CAUSE pF DEATH?
<br /> ^ Unknown If pregnant wkhin the paM year ^ YE$ ^ ND
<br />°'
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, Tarm, street, factory, offlca building, construction site, etc. (Specify)
<br />
<br />~i' 22d. INJURY AT WORK? 229. DESCRIBE NOW INJURY OCCURRED
<br />O
<br />N
<br />^YES ©NO
<br /> 22f. LOCATION OF INJURY -STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (fdo., Day, Yr.) _ ~ 24a. DATE SIGNED (Mo., Day, Yr.i 246. TIME OF DEATH
<br /> ~ W ~'r~ ~ February 11, 2010 Approx. 08:00 AM
<br /> ~ 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ~ '~
<br />24c. PRONOUNCED DEAD (Mb.
<br />Day
<br />Yr.) 24d. TIME PRONOUNCED DEAD
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<br /> g t4 -' ~ ~ = Februa $, 2010
<br />~ 21:35 PM
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<br />o 39d. To the beet or my knOwl0dp0, death oCCUrced at the time, date and place
<br />and due td the caueele) etAWtl. (Signature and Title) ~' ~ O
<br />B = p y4a• On the baele Of BXaminatlon and/dr inveetipatiOn, in my OpIr11On death occurred at
<br />the time
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<br /> ~ ~ ~ o Jack Zitterkopf, Hall Deputy County Attorney
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATHS 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WA$ CONSENT GRANTED?
<br /> ^ YES ^ NO ^ PROBABLY ® UNKNOWN ^YES ®NO Not Appllca6le N 26a Is NO ^YES ^ Np
<br /> AD I ( HY N, R N A RN ) ype Or r n )
<br /> Jack Zitterkopf, Hall Deputy County Attorney, 231 S. Locust, P,O. Box 367, Grand Island, Nebraska, 68802
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> February 16, 2010
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