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STATE OF NEBRASKA
<br />WNEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBR.45KA DEPARTMENT OF HEALTH AN47 h►UJ'�AN,S€RVICES, IT GERTIFI�S
<br />THE BELOW TO BE A TRUE COPY pF THE ORIGINAL RECORD �N FILE WITM THE N�BR,4SKA L�EPARTMENT 01�' ANp
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITpRY FOR VIT'A1 R�CORDS. ,:' `+.
<br />e
<br />DATE OF ISSUANCE �� • r
<br />/��� � ' ,
<br />11 /17/2010 sraN«� 5. cao��k� " ,, P„;
<br />2 0 1 Q 0 9 4 5� ASSIST'A�VT 5�11"�"R�GI�TRAR ,,
<br />DEP'AR�M�N7"C9F'�M�EAL7"hl -,4ND
<br />LINCOLN, NEBRASKA HUMi1l�C5�'RVIC�S
<br />STAtE OF NEBRASKA - DEPAR7MEN7 OF HEALTH AND HUMAN S�RVI�'�S A° ,�' �° ;"=' ',. ti'. '1"- •' �� ��
<br />r.�R�ri��ro�rF n� nFnrH : � , . �: � „��,° • . . -� a: 10 03292
<br />1. DECEDENT'S•NAME (Flrst, Middle, Last, Sufflx) 2. SFJ( 8: ATE OF DEA7H, �hW., Day, Yr.)
<br />Janet Ga Schnetder Female November 14, 2010
<br />4. CI7V AND STATE OR TERRI70RY, OR FOREIGN COUNTRY OF BIRTH 5a. A(3E • Last Blrthday 6. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTN (Mo., Day, Yr.)
<br />(Y�'s•) MOS. DAYS HOURS MINS.
<br />Hawarden, lowa 75 November 19, 1934
<br />7. SOCIAL SECURITY NUMBER ea. PI.ACE OF DEATFI
<br />507-52-25,43 HOSPITAL � IrlpatlBM OTHER Q NU1'eing NOmB/LTC � HpEpICe FaClllty
<br />Bb. FACILITY-NAME (If not Inadtution, giva street and numbar) � ERlOutpatlant � Dacedent's Nome
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<br />_ _ _.
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<br />1519 .Nortti Custer AV911u6 - - - _ _ �- _ - - _ CI � - _ rt7 diFar f5p.c�M
<br />� ac. CITY OR TOWN OF DEATH (Include Zlp Code) 8d. COUNTY pF DEA7H
<br />c Grand Island 68803 Hall
<br />� J 9a. RESIDENCE-$TATE 9b. COl1NTY 9c. GITY OR TOWN
<br />Nebraska Hall Grand Island
<br />z
<br />� ed. S71tEET AND NUMBER e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />T 1511 Nprth Custer Avenue 68803 � ves ❑ No
<br />n 1Da. MARITAL STATU5 AT TIME OF DE4TH � Nlarrlad ❑ Navar Married 10b. NAME OF SPOUSE (Flnt, Mlddle, Laat, Sufflx) If wHa, gNe malden name
<br />� ❑ Marcled, but saparated ❑ Wldawed ❑ Dlvorced ❑ Unknown RIChBfd SCh118id8f
<br />m
<br />� 11. FATFIER'S•NAME (Flrst, Mlddle, Last, Sufflx) 12. MQTHER'$-NAME (Flnt, Mlddle, Maiden Surname)
<br />� Lloyd Anderson Brynece Swift
<br />a 1S. EVER IN U.S. ARMED FORCE89 Glve dptes af servlCe If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />� �vea, No, or Unk.) NO Richard 5chneider Spouse
<br />g' 15. METHQD OF DISPp31TIQN 18a. EMBALMERSIGNATURE 786. LICENSE Np. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ Burlal ❑ Donatlon
<br />Not Embalmed November 16, 201p
<br />� Crematlon ❑ Entombment �gd. CEMETERY, CREMATORY OR OTNER LOCATION CITY / TOWN STA7E
<br />[] Removal [] Othar (Spacify)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL FiOME NAME AN� M/ULING ADPRESS (Straat, Clty or Town, State) 77b. Zlp Code
<br />All Faiths Funeral Home, 2929 S. Locust 5treet, Grand Island, Nebraska 68801
<br />ee nstructions an exam es
<br />16. PART 1. EMa� thr chaln e( avrMa•�Isaaau, InJudoa, or CompllcaTlonfdhat dlroCtly uuaad iM drNll. DO NOT rntrr tarminal rvrnq wch aa cardlac YYrost, ; AppROXIMATE INTERVAL
<br />n�plratory arnaf, ar wMricular flbrlllatlon wHhaut fhowlnq thi aNOloqy. UO NtlT A88REVIATE. Enh� vnly onr cauw an a Ilna. Adtl addlllOnal Ilnat If neCeNary.
<br />IMMEDIATE CAUSE: ; onsat to death
<br />IMMEDIATE CAUSE (Flnal a) Metastatic Colon Cancer ; 2 Years
<br />dlseaaa or conaitton re�uninp
<br />In daath� DUE TO, OR A$ q CPN$EQUENCE OF: 7 onset to death
<br />Srqwmlally Iirt condltiona, it b)
<br />any, Iwdlnq to thr wuw Ilatrd
<br />on une a. DUE TO, OR AS A CONSEQUENCE OF: � orl8at to deeth
<br />EMsr the UNDERLYING CAUSE G)
<br />(dl�sus or In1ury that Initlated
<br />eha avent� resulting In daath� pUE TO, OR AS A C�NSEQUENCE OF: � onsat to death
<br />LAST d)
<br />18. PART II.OTHER SIGNIFICANT CONDI710NS�CondlGVns contrlbuting to the death hut not re�Wting In tha underlylnq cause ylvan In PART I. 19. WAS MEDICAL EXAMINER
<br />QR GORONER CONtAC7EDT
<br />� ❑ YES � NO
<br />w 0. IF FEMALE: 21a. MANNER OF DEATW Y1b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED7
<br />LL
<br />� � Nat pregnant wllhin paat ysar � Natural � Homlclda � Ddwdppantar � YES � NO
<br />� � ProO�an! a1 tlme af death � AcCldant � Pendinq InVeatipatlon ❑ Paawnqar
<br />� Nal praynant, but propnant wtthln 4Y daya of daath Sulcldr Could not be detsrminsd ❑ Podratdan Z1 d. WERE AUTQP$Y FINDINCs3 AVAILABLE
<br />� � Not pnpnant, but prrpnant 47 tlayr to 7 yaar 6etore Aeath � � � Othrr (Sprclfy) TO CqMPLETE GAU$E OF DEATH9
<br />'Y7
<br />� � Unknown IT pnanant wlthln thr paet yaar ❑ YES � NO
<br />a ' 22a. DATE QF INJURY (MO., Day, Yr.) 22b. TIME pF INJURY 22C. PLACE OF INJURY•qt home, Tarm, sfr6et, factory, oiflCe 6ullding, Con�Wctlon slte, etc. (Specify)
<br />�
<br />�' 22d. INJURY A7 WORK7 22e. DESCRIB� HOW INJURY OCCURRED
<br />O
<br />F" ❑ YES ❑ NO
<br />22f. LOCATION pF INJURY -$7REET & NUMeER, APT.NQ. CITYRpWN 8TATE ZIP CODE
<br />23s. GATE OF D�ATH (Mo., Day, Yr.) 24a. DA7E $IGNED (Mp., bay, Yr.) 24b. TIME OF DEATH
<br />� � November 14, 20i0 � � �
<br />�� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH �� k� 24c. PRONOUNCED DEAD (Mo., Dsy, Yr.) 24d. TIME PRONOUNCE� DEAD
<br />� Npvember 16 2010 09:�5 PM ���
<br />$�� 3d. To tM bsst of my knowNdys, de�th occurrsd at tM tima, data and place Z�e, On tha 6a�1� of axaminatlon anNor Investlpatlon, In my opinlon death occurrad at
<br />E �nd dw to tM auaN) atatsd. I8lpnriurc snd Tkk) $�� the tlmo, data and plap antl tlur to Mr c�uw�a) ftahC. (Slpnatun and Tltlr)
<br />~ � Jana VanWie, MD ~ � a
<br />25. DID TOBACCO USE CONTRI6UT� 7p 1'HE DEATH7 28a. HAS ORGAN OR 71SSUE DONATION BEEN CQNSIDERED7 266. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicabla If 28a Is NO ❑ YES ❑ NO
<br />. A I ypa or rint
<br />Jana VanWie, MD, 2444 W. �eidley Avenue, Grand Island, Nebraska, 688D3
<br />2aa. RE(iIS7RAR'S 81GNA7UItE 28b. DATE FILED BY REGISTRAR (Mo., Pay, Yr.)
<br />November 16, 2010
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