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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTl�l��,4'M� �14J(�QEI�v��cq��CFS, IT CERTIFIE�
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASI� tZ '�`i� 5 7�0 E AND
<br />HUMAN SERVICES VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR l�T R �� �i, °
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<br />DATE OF ISSUANCE �'
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<br />03/25/2011 2 0110 2 611 sT�4N�� � e�# . � Tr ��'-_
<br />as��rAn���r�kl�c�.��. � .
<br />DEP�114T,I�qE�l���TEI1! yThl �&, � '�
<br />LINCOLN, NEBR.4SKA HUMA�jZS����` � �� ,,,,�, '
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES�,t'„ �� ��',� r�1 �''� O OZOO'I
<br />CERTIFICATE OF DEATH ' '' r • ` ' "� `� ,�
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<br />DECEDENTS-NAME (FMst, MIddM, lasQ Sufllx) 2. SEX ' E� S. �A (�F.[�A'�H {Mo., Day, Yr.)
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<br />Grand Istand, Nebraska
<br />SOCL4L SECURITY NUMBER
<br />507-34-5605
<br />. FACILfTY-NAME (R not Instkutlon, yM Mrost and
<br />St. Francis Memorial Health Center LTC
<br />, C1TY OR TOWN OF DEATM (I�cluda Zlp Code)
<br />Grand Island 68803
<br />�
<br />1GE • Last Bkthday . UNDER 7 YF.�
<br />(YR•) MOS. DAYS
<br />74
<br />8a. PLACE OF DEATN
<br />HOSPRAL � InpatlsM
<br />� ER/Outpatlent
<br />❑ oa►
<br />. RESIDENCE3TATE 9b. CWNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />. STREET AND NUMBER . APT. NO. 9f. ZIP CODE 9q. INSIDE CfTY LINMTS
<br />3536 W. Air Rd 68803 ❑ rES � n►o
<br />a. MARRAL STATUS AT TIME OF DEATH � MartIW ❑ Newr M�rtkd 1pb. NAME OF SpOUSE (Fkst, Middk, Last, SWNz) If wMe, yNe m�ldsn mms
<br />❑ Marriea but separatad ❑ widoww p otiw�.a ❑ u��,own Wayne Schumacher
<br />. FATHER'&NAME (FNst, Middl�, Last, Sulfiz) 12. MOTHER'S-NAME (Fkst, Middb, Nl�id�n Sum�ms)
<br />Irven F Brown Ema Luebbe
<br />. EVER IN U.S. ARMED FORCES? Glvs dabs of ssrvks H Yes. 14a. INFORAAIWT-NAME 74b. RELATIONSHIP TO DECEDENT
<br />n.s, No, or unk.► No Wa e Schumacher Husband
<br />. METHOD OF DISPOSfTION 16a. EMBALMER�SttiNATURE 16b. LICENSE NO. 16c. DATE (MO., �y, Yr.)
<br />� BOf �'� � °onatlon Not Embalmed July 19, 2010
<br />� Crem�tlon Q Erkombm�nt �gd. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Rertqval ❑ Olher ISPe�KY)
<br />Wesdawn Memorial Park Cemetery Grand Island Nebraska
<br />Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />!. PART I. EM�� tM chax� M�vamr ��n, InJurla� a eaipNallom�qnt Mnetly awM tM MtIN. DO NOT �nMr bnMnal w�M� wch u uMlae amst. .
<br />rupi�tory amM, w wntrieWV Bbr111Nlon wMhout Mowbq 1M �Mobpy. DO NOT ABBREVIATE EnMr o�y on� ew» on a IIM. AdA addltbnal IN»s H roouwry.
<br />IMMEDIATE CAUSE:
<br />IMMEDU►TE CAUSE (Final a) Respiratory Failure
<br />01� or conditbn raultlnp .
<br />1° �� DUE TO, OR AH A CONSEQUENCE OF:
<br />s.�.�wnr �ue ��aro�,., n b) Non-small Cell Lung Cancer With Metastasis
<br />Nn, �aema a a» enn. iaew
<br />���� DUE TO, OR AS A CONSEQUENCE OF:
<br />Em.ruw uNOEfu.viNG WwSe �)
<br />(dlaaw or inJury Mat Initlabd
<br />��" """ ^„'�"� �" �'� DUE TO, OR AS A CONBEQUENCE OF:
<br />u►sT d)
<br />OTHER
<br />Female Jul��i7, 2010
<br />5e. UNDER 7 DAY 8. OATE OF &RTH
<br />HOURS MIN3.
<br />October 26, 1935
<br />OTHER � Nunirp HomeILTC [� Nospice Facllity
<br />� Decad�flt's Homs
<br />O on� fsn.cKr)
<br />couNrv oF o�►sH "
<br />Hall
<br />the underlylrq quse plven In PART L I 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES � NO
<br />). IF FEMALE: 27a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED7
<br />� NM prpnaM wNhla pa�t y�ar � Natunl � HonYC10� � DrIwHOpsrator
<br />� Propnant at qm� of death � Aedd�M � W�Minp Inw�tlpadon ❑ Pau�np�r ❑ YES � NO
<br />� Not pnpnan, MA p�pmM wipdn r4 Gys of Owdi � Wtlntrian 41d. WERE AUTOPSY FINDINGS AVAILA
<br />� Na w•o�M, ew P�o.M a am so � r••r e.ro� a..a� ❑ su�aa � cowa na a d.am�Ma O � r �g�c�� TO COMPLE7E CAUSE OF OEATH?
<br />� UMua�wn If pnp�aM wphin tM prt ypr ❑ YFS ❑ NO
<br />ta. DATE OF INJURY (Mo., Day, Yr.) 22b. TMAE OF INJURY Z2e. PLACE OF IN.IURY-At homa, hrm, stresf, hetory, oftlee bulldiny, comtruetlon site, etc. (Sp�ely)
<br />INJURY AT WORK? I22e. DESCRIBE HOW INJURY OCCURRED
<br />❑ YES ❑ NO
<br />LOCATION OF INJURY • STREET � NUMBER, APT.NO. CRY/TOWN
<br />� July 17, 2010
<br />� 2Sb. DATE SKiNED (Mo., Day, Yr.) 23c. TMAE OF DEATH
<br />� Jul 19, 2010 12:20 PM
<br />� . To lM bat oi my knowMdp�, WMp oxunM at tM tlm�, dal� anA p4a
<br />and dw W lM auap) �d.13�Y� �d TMM)
<br />� Jennifer L. Brown, MD
<br />YES l J NO I 1 PROBABLY Ll UNKNOWN
<br />Jennifer L. Brown, MD, 729 North Custer Avenue,
<br />STATE
<br />rm. z� coa.
<br />68803
<br />; APPROJOMATE INTERVAL
<br />; o�aet to dqth
<br />; 1 Month
<br />�
<br />7 omst to d�alh
<br />; <1 Year
<br />; omet to datl�
<br />7 oosetto d�ath
<br />Z�P CODE
<br />� 21a. DATE SIONED (Mo., Wy, Yr.) 21b. TIME OF DEATH
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<br />� 21e. PRONOUNCED DEAD piAO., Day, Yr.) TAd. TIME PRONOUNCED DEAD
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<br />E �� 2N. On tM Wda ot�nminatlon mNor Inw�dY�0. In mY oW� Malh aceum0 at
<br />� tM nm�. daq anA P� and dw to eM ewN(�i M+Md. (Sip�n�fun �ne rMMi
<br />` a
<br />YES � NO
<br />and Island, Nebraska, 68803
<br />K ss■ � rio n vES r � No
<br />28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />July 20, 2010
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