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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND MUMAN SERVICES,'IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FItE WITH THE NEBRASKA flEPAR�T�T,_OF HEALTM AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL-.Rf�O l�� ,�' ��j � °,
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<br />DATE OF ISSUANCE s ',�
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<br />DEP/II��NT�Q ���FF�1�ND•• ;�� ' �
<br />' LINCOLN, NEBRASKA HUNJtIA�:5�ERik�� .t `� .�� ; ',�' f' ,
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC�ES' ;� '� r� �� e ' ' �'' ''
<br />I CER IFICATE �OF DEAT � � � � �'.� �`� ° ��°� �� `�� ° �
<br />�� 1. DECEDENTS-NAME (Flrst, Mlddle, Leat, ' Suffix) � 2 SEX ... �. 3. b �0(F�D�TH (f�a' Day�Yr:)
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<br />Ben Lavere Schoneberg Male Ocfob�r'1;-2010 �
<br />4. CITY AND STATE OR TERRffORY, OR POREICiN COUNTRY OF BIRTH Ba AGE•Lest Blrthdey 86. UNDER 1 YEAR Be. UNDER 1 DAY � 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Yra) CA09. � DAYS HOURS MINS.
<br />Wood River, Nebraska 85 February 23, 1925
<br />7. 80CIAL SECURITY NUMBER Ba PLACE OF DEATH
<br />5Q6-22-6206 HOSPRAL: Q Inpaderrt OTy�,O Nura�ng Homa/LTC � Hosplca Faciliry
<br />�' 8b. FACILITY-NA�AE (li rtot Uistltutlon, give street and number) ❑ ' - ❑veeedenYeNome -- - - --
<br />Veterans Affairs Medical Center ❑ °OA ❑oe�'BKsP�v�
<br />Sa. CITY OR TOWN OF DEATH (Includa Zlp Code) 8d. COUNTY OF DEATH
<br />Grand Island 688ti3 Hall
<br />9a RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />Nebraska Hall Grand Island
<br />� 9d. SIREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE 9g. W SIDE CIiY LIMrt°3
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<br />� 206 Wetzel St. 68801 � r� ❑ No
<br />� 10a MARITAL STATU9 AT TIME OF DEATH � dlaMatl ❑ Never INarried 10b. NAME OF BPOUSE (Flrst, 0.71dtl1e, Last, Sufflx) if wifa, g(ve malden nama.
<br />� ❑ mmr�ed 6ut eeparated Q Widowed ❑ Divorced ❑ unw�own Eunetta Mamie Rathman
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<br />� 11. FATHER'S-NAME (Flrst, � Middle, Lest, � Suftix) � 12 MOTHER'SNAME (Flrst, M(ddle, Mald�n Sumame) �
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<br />� Ben - Emil Schoneber Vera Tuffs
<br />� 13. EVER IN U.S. ARMED FORCES? dffiea oT eervice HYea 14a INFORd1ANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />� 1 /27/45,�11 /17/46
<br />(Yes, No, or Unk) yeg Eunetta Mamie Schoneber Wife
<br />18. METHOD OF DISPOSI710N 1Ha EMBALMERSIGNATURE 16b. LICENSE N0. 18c. �ATE (AGo., Day, Yr.)
<br />��"�' � °onffi ' ° " Not Embalmed October 2, 2010
<br />�Cremation �EMOmbmeM � .
<br />�Rmnova� �otheMapec�y� 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITYlTOWN sTATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a FUNERAL MOME NAME AND MAILIN6 ADDRESS (Sheet, City or Town, 8tete) 17b. ap Cude
<br />Ali Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH (See Instructions and examples)
<br />�18. PART L EMa�tha nhaln of everrta .�eeagea, fnJuries or wmpilcatl�ne-tPat tOrecHq uumed tha tleath. 00 NOT anter tarminel events such ae cerdlec arrest, � AppROXIMATH INTERVAL
<br />respiratory erteat or veMricWarflbNilmion wlMOUt ehowing the etlology. DO NOT ABBREVIATE Enter onty mre eeuae ort a Me. Atld fldaifianal Iimm � necesaerp. �.
<br />IMMEDIATE CAUSE: - � onset to death
<br />IMAAEDIATE CAUSH �Flnal �
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<br />disease or eondfUon resultlng a) �
<br />In death) �-'
<br />�UE TO, OR A$ A CONSE ENCE OF: � otreet to death
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<br />SequeMialty tist conditlo�. lf b � . ��
<br />eny, tead(ng to tha cai�ae Ilated \ 6
<br />on Bne a DUe T0, OR AS A CONSEQU CE OF: � onset to death
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<br />.. Emerthe UNDERLYINO CAUSE �) '� �
<br />(dlaeese or InJury that InWated m � � d bc 0., n 0. �J o R �
<br />!he evems resWBng in deafh) DUE TO, OR AS A CONSEOUENCE OF: ; o�at to death
<br />LAST � �
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<br />18. PART I4 OTHER SIGMFlCANT CONDITIONS-Conditlone co�itiuti� to death but rtot reaultln e underiy�ng use given in PART 6 18. WAS INEDICAL EXAMINER
<br />p�C���e ORCORON�M'ACTE07
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<br />Q. � �\ � '� 11 C �Il l.O� C C YES NO
<br />W 20. IF FEMALE: 21a MANNER OF DEATH Z1b. IP SPORTA � WJURY 21c. WAS AN A OP PERFORI'dE�?
<br />H �Not pragnaM wWtin past year Natural ❑ Homicide ❑ DriverlOperator ❑ YES NO
<br />� ❑Preg�rentatdrtreoPdeath � ❑ACOident ❑Pendinglnreatt8��n ❑Paseenger 21d.WEREAUTOP3YFWDINGSAVAILABLE
<br />❑Not pregneM, but pregnent wifhtn 42 days of death ❑ SuiWde ❑ Could not be determined ❑ Padestrlan TO COMPLETB CAUSE OF DFATH7
<br />� ❑ Not pregnant, but pregnaM 43 dapa to 7 year betore death ❑ Other (Speclfy) � yEg � NO
<br />� [�Unlmwm H pregnant wkhin.the past year
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<br />0 82a DATE QF INJURY (Mo., Day, Yr.) 22b. TIME OF iNJURY 22c. PLACE OF INJURY-At home, farm, streat, factory, oiflea building, eonatructlon slte, ete. (Speclfy)
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<br />� 22d INJU T W RK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />�"' ❑ YES NO � -
<br />22f. LOCATION OF INJURY - 9TREET & NUMBEIt, APT. NO. CITY?ONM STATE ZIP CODE
<br />23a DATE OF DEATH (Mo., Day, Yr.} z 24a. OATE SIGNED (Ma., Day, Yr.) 24h. TIME OF DEATH
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<br />,�� r 23b. DATE SIONED (Mo., Day, Yr.) 23a. TIME OF DFATH , y�� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
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<br />m V 23d. To the best W my Imowiedge, death occurted et the tlme, date and ptece � W Z 24e. On the basis af examinatlon and/or investlgatlon, in my opinton death occurt�i
<br />F� d due to the cauae(s) eteted. (9lgnature and Tit(e) o�� at the time, �date and piace and due to ffia cause(s) etated. (Slgneture atM Titla)
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<br />28. Di� TO � CO USE CONTRIBUTE TO E D TH? 28a. HA9 OROAN OR TIS U OONA710N BEEN CONSIDERED? 28b. WA9 CONSENT ORANTED?
<br />❑ YES ❑ NO ❑ PROBABLY NKNOWN ❑ YES NO. Not Appticebfa R 28a Is NO� ' ❑ YES NO
<br />27. NAME, TITLB AND ADDRESS OF CFJ2TIFlER (PHYSICIAN, PHYSICIIW ASSISTANT, CORONER'8 PHYSICIAN OR COUNTY ATTORNE`n (Tgpa or PflM)
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<br />28a. REOIS7RAR'S SIGNATURE ' 28b. DATE FlLED BY REGISTRAR (tbo., Oay, Yr.)
<br />P � ocr � 2 zo�a
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