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STATE OFNEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS..
<br />DATE OF ISSUANCE ��.�`��� �.! . • `�� '
<br />STANL�Y S,w GOE3PER `
<br />01 /13/2010 2 0110 2 5 2 8 ASSISrANT STA,TE REC'iISTRAR
<br />DEPARTMENT OF HEALTH AND
<br />LINCOLN, NEBRASKA HUMAN SERIIICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES ' 'I O OOO4H
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S-NAME (First, Middle, Last, SuHix) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Earl Wesley Schroder Male January 4, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last BiRhday b. UNDER 7 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (MO., Day, Yr.)
<br />(Yrs.) MOS. DAYS HOURS MINS.
<br />Ohiowa, Nebraska 85 March 11, 1924
<br />7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />508-18-2636 HOSPITAL � Inpatient OTHER � Nursing Home/LTC � Hospice Facility
<br />3b. FA�!LlTY-MA"RE (If not Institution, give street and number) � ER/Outpatient ❑ DecedenPs Home
<br />a'
<br />� Saint Francis Medical Center ❑ DOA ❑ Other (Specify
<br />U
<br />� 8c. CITY OR TOWN OF DEATH (Include Zip Code) Sd. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />z
<br />� 9d. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />T 1704 N. Grand Island Ave. 68803 � YES ❑ No
<br />a 10a. MARITAL STATUS AT TIME OF DEATH � Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />v
<br />d
<br />!� ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Florence Domeier
<br />d
<br />9 11. FATHER'S-NAME (First, Middle, Last, Suffix) � 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br />� Fred Schroder Louise Hopkens
<br />�' 13. EVER IN U.S. ARMED FORCES? Give dates of servlce if Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� (Yes, No, or unk.� Yes 03/30/1943-01/29/1946 Florence Schroder Wife
<br />a 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO. 16c. DATE (MO., Day, Yr.)
<br />F � s�r�ai ❑ Donatfon Derek Apfel 1240 January 8, 2010
<br />❑ Cremation ❑ Entombment 16d. 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, City or Town, State) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam les
<br />18. PART I. Enter the chain of events--diseases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ; APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NO7 ABBREVIATE. Enter only one cause on a Iine. Add additional lines if necessary.
<br />IMMEDIATE CAUSE: ; onset to death
<br />IMMEDIATE CAUSE (Final a) Metastatic C2rcinoma Of Lung ; 6 Months
<br />uisnasn ur cmiuilion rnsw7ing
<br />in tleath) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Sequentially lis[ conditions, if b)
<br />any, leading to the cause IlsteA
<br />on iine a. DUE TO, OR AS A CONSEQUENCE OF: ; Onset to death
<br />Enterthe UNDERLYING CAUSE C �
<br />(disease or injury that Initiated
<br />the events resulting in Ceath) DUE T0, OR AS A CONSEQUENCE OF: � onset to death
<br />LAST d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS•Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br />Ischemic Heart Disease OR CORONER CONTAC7ED?
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />� � Not pregnant within past year � Naturel � Homicide � Driver/Operator � yE$ � NO
<br />W � Pregnant at time of death Passenger
<br />V � Accident � PenUing Investigation ❑
<br />T � Not pregnant, but pregnant within 42 days of death � Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� � Suicitle � CoWtl not be tleterminetl TO COMPLETE CAUSE OF DEATH?
<br />� � Not pregnant, but pragnant 43 days to 7 year before tleath � Other (Specify)
<br />� � Unknown if pregnant within the past year ❑ YES ❑ NO
<br />N
<br />�' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />E
<br />0
<br />�
<br />.n 22d. INJURY AT WORK1 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />F' ❑ YES ❑ NO
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) _} 24a. CATE SICldED (MO., Day, Yr.) 24b. TIME OF DEATH
<br />r� Ja��uary 4, 20 i0 a ��
<br />��� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH m= k r 24c. PRONOUNCED DEAD (MO., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E � Z Janua 11, 2010 08:05 PM E a a Z
<br />N
<br />° u Q O Z3d. To the best of my knowledge, death occurred at the time, date and place '�' W z� 2qe, On the basis of examination antl/or investigation, in my opinion death occurred at
<br />0 o and tlue to the cause�s) sWted. (Signature and Title) o � p the time, date and place and due to the cause�s) stated. (Signature and Title)
<br />~� David R. Colan, MD `' � s
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />❑ YES � NO ❑ PROBABLY ❑ UNKNOWN ❑ YES � NO Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRE F ERTIFIER (PHY I IAN, HY I IAN I TANT, RONER' PHY I IAN R UNTY T RNEY) (Type or Print)
<br />David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yc)
<br />January 13, 2010
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