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STATE OF NEBRASKA
<br />WG/EN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH Al~fd'")'NNI'M~41\l ~~RVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA,~MA ~l~~l~.~#f€7-M~I~T~(~F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR I~fTA~' ECO St..:' ':•`.. ~ ~
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<br />DATE OF ISSUANCE ~~/~ 1 ~ ' ,,
<br />sip ~ ~ zo,o 2 010 o s s 3 s STAI'~E?' S. ooPER ~ ~ . .
<br />ASSIBT,4N7~TTE~~C~ISTRAR '
<br />DEPRIY7'INE AND
<br />LINCOLN, NEBRASKA HUM,4hy~ ~ER~,VICES .~
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES tP~' ,~ ~~ Z ~ r ~
<br />CERTIFICATE OF DEATH ~' ; ~.~' ~ 7:~`~~ ~
<br />1. DEGEDENTS•NAME (First, Middle, Last, Suffix) 2. SEX . pg7E H (Mo., ay,Yf.)
<br />Kath n Mar aret Schloer Female Se tember 4,`2(310
<br />4. CITY AND STATE OR TERRITORY, OR FOREI4N COUNTRY OF BIRTH 5a. AGE•Last Birthday bb. UNDER 1 YEAR 5c. UNDER 1 DAY e, DgTE OF 61RTH (Mo., Day, Yt:)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br />Minot, North Dakota 70 December 4, 1939
<br />7. SOCIAL SEGURITY NUMBER 8a. PLAGE OF DEATH
<br />501-44-7693 HOSPITAL: ®Inpatient OTHER: ^ Nureing HomalL7C ^ Woapice Facility
<br />Bb. FACILITY-NAME (Pf not Institution, give street and number) ^ ER/qutpatlent ^ Decedent's Home
<br /> DOA .. ~]dther(sPe~f~) ., .....
<br />BryanLGH Medical Center East
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
<br />Lincoln 68508 Lancaster
<br />9a. RESIDENG@sTA7E 94. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />9d, STREET AND NUMBER 9e. APT. NO. 9f, ZIP CODE 9g. INSIDE CITY LIMITS
<br />224 E. 21st 68801 ®vea ^ No
<br />18a. MARITAL s7ATUS At TIME OF DEATH ^ Married ^ Never Married 18b. NAME OF SPOUSE (Flat, Middle, Laaq suffix) It wlfi, glue maiden name.
<br />^ Marrlad, but separated ®Widowad ^ Diverted ^ Unknown
<br />James R Schloer
<br />11. FATHER'S-NAME (First, Middle, Laat, $uTflx) 12. MOTHER'S-NAME (Firer, Middle, Malden Sumama)
<br />Walter Kor el Mar aret Hennes
<br />13. EVER IN U.S. ARMED FORCES? Glve dates at service if Vas. 14a. INFORMANT-NAME 14b. RELATIONSWIP TO DECEDENT
<br />(Yes, No, ar Unk.) NO Che I Green Dau hter
<br />18. METHOD OF DISPOSITION i6a. E LM -SIGNATURE 166. LICENSE NO. 18c, DATE (Mo., Day, Yr.)
<br />®Burlal ^Donatlon ~ ~ r, ~ ~ Se tember 11, 2010
<br />^cromation ©t:ntamament
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<br />^Itemavel ^Other(apeclry) STATE
<br />18d.CEMETERY REMATORYpRpTHERLO ON CI7Y/TpWN
<br /> Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL WOME NAME AND MAILING ADDRESS (Sheet, City or Town, State) 17b. Zip Code
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam lea
<br />1a. PART I. ennr tIN ehe/n d ewMd . alMaeas, IniurMa, er cemplk:a[lene-that directly ceuga tM Meth. b0 NOT erlNr pnnlnal ewnu loch as Car4lu awea4
<br />APPRpXIMATE INTERVAL
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<br />nspiretory amat, ar ventricular tlprlllaaon wlthput ahowlna ehe evoteay.DGLN07 A99REVIATE. Enter anl~. one ~e ~q a Ilna. pdd eddltloual IIne~If necrsfary.
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<br />IMMEDIATE CAUSE: t vnaet to death
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<br />IMMEDIATE CAUSE (Final t - - -
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<br />DUE TO, OR AS A Cp SEgUENCB OF: t onset to death
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<br />any, leading to the cause listed
<br />on Iina a. DUE TO, OR AS A GONSE ENCE OF: t Driest to death
<br />Enter the UNDERLYING CAUSE c) I
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<br />(disease or InJury that Inltlated
<br />the evartts resulting in death) DUE TO, OR AS A CONSEpUENCE OF: I onset to death
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<br />18. PAR71I. pTHER SIGNIFICANT CONDITIONS-Condlelons contdbuting to the death 6ui not resulting in the underlying cauee given In PAR7I. 1B. WAS MEDICAL EXAMINER
<br /> OR CpRONER CONTACTED?
<br /> ^ YES ~Np
<br />r~F FEMALE:
<br />of pregnant within past year 21a. MANNER OF DEATH
<br />NaWral ^ Homicide 214. IF 7RANSPpR7ATION INJURY
<br />^ DrivarlOparetor 21 c. WAS AN AUTOPSY PERFpRME07
<br />^ YES O
<br />^ Pregnant at time of death Accldmt ^ Pending Investigadan ^ Passenger 21d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />^ Not pregnant, but pregnant wlthhi 42 tlays vi death ^ Sulclda ^ Could no! be determined ^ Pedestrian TO COMPLETE CAUSE OF DEATHS
<br />^ Not pregnant, but pregnant 43 days to 1 year before death ^ Other (Specify) ^ YES ^ NO
<br />^Unknown ii pregnant within the past year
<br />22a. GATE OF INJURY (Ma., Day, Yr.) 22b. TIME pF INJURY 22c. PLACE DFINJURY-At home, farm, street, factory, oRlce 6ullding, cvnatructian site, etc. (Specify)
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<br />22d, INJURY A7 WORK? 22e. DESCRIBE HOW INJURY OCCURRED
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<br />22t. LOCATION OF INJURY - STREET 8 NUMBER, APT. ND. CITYITOWN _ STATE PIP CODE
<br />23a. DATE OF DEATH (Ma., Dsy, Yr.) ~ 24a. DAtE SIGNED (Mv., Day, Yr,) 24b. TIME OF DEATH
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<br />F- 23b. DATE SIGN (Ma. Dsy, Yc) 23c. TIME OF DEATH ~ ~ O 24c. PRONOUNCED DEAD (Mp., pay, Yr.) 24d. TIME PRONOUNGED DEAD
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<br />R4e. On the 6asls of axaminativn andlor Invea9gatlon, In ttry opinion death occurred
<br />23d. Ta the bast of my knowledge, death Occurred at the time, date and place
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<br />(Signature and ?ilia)
<br />lace and due to the cause(s) stated
<br />~' ~ ~ at the time
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<br />2E. DID TOBACCO USE CONTRIBUTE TO THE EA7H7 Rea. H ORGAN OR TISSUE DONATION BEEN CDN$IDERED7 26b. WAS CONSENT GRANTED?
<br />^ VES ^ NO ©PR08ABLY ~ NKNOWN ES ^ NO Not Applicable If 26a le NO ^VES O
<br />27. NAME, TITLE AfgD DDRES$ OF CERTIFIER PHYSICI , PHYSICIA ASSISTANT, CORDNCR'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
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<br />28a. TRAR'S SIGNATURE 286. DATE FILED BV REGISTRAR (Mv., Day, Yr.)
<br /> SEP 0 9 2010
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