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<br />y STATE OF NEBRASKA
<br />WHEN THIS COPY CARRl'ES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H�ALT,H_.��IND Hl�'MA'N�SERVICES,IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FICE WITH THE IVEBRA�LC,4�,El�A��t�'!�%I�N AIVD
<br />, HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOf�;I"/I�L' �E-�C?#T�S.•.,;�` >, ��`:; �
<br />A '"+� ��� f� �QNIIt C
<br />DATE OF ISSUANCE ,� ��� �����r � � �,. ...
<br />01/14/2011 2 0110 S 0 5 9 ':7.q�L�� ,,, a � � ! � R ` a+�. ,�
<br />A��TA ,�` ,
<br />d[P.�R�'!k1'�N7"LTF•HEALTH;AN63 y'
<br />LIIUCOLN, NEBRASKA HUM�4'J , � .. �'�� �A , ' i
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVIC�� �,����; e��' �'`° ``, ' 1
<br />g . � 9 �� „�"' _'11 00098
<br />CERTIFICATE OF DEATH "„'��'�' , ,,, � �'�� �
<br />1. DECEDENTS•NAME (First, Middle, Last, Suffbc) 2. SEX �'x, �,�3: DkY� O� D TH (Mo., Day, Yr.)
<br />Darrel �uge�e Schwaderer Male °Jahuary 10, 2011
<br />4. CITY AND STATE Oit TERRITORY, OR FOREIGN COUNTRY OF BIRTH ba. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY 8. DATE OF BIRTH (MQ., Day, Yr.)
<br />(�'►$•) MOS. DAYS HOUR$ MINS.
<br />Loup Clty, Nebraska 72 October 21, 1938
<br />7. SOCIAL SEGURITY NUMBER Ba. PLACE OF DEATH' ---- --
<br />508 OSPRAL � Inpade� OTHER � Nursing Home/LTC � Hosplce Faciltty
<br />eb. FACILITIf•NAME (H not Instltution, glva street and number) � ER/Outpadent ❑ DecedenPs Home
<br />�
<br />� Wedgewood Care Center ❑ ooA ❑ aner �speciry)
<br />� BC. CITY OR TOWN OF DEATH (Include 2Ip Code) Sd. COUNTY OF DEATH
<br />e Grand Island 68803 Hall
<br />� 9a. RESIDENCE-STATE 9b. COUNTY 8e. CITY OR TOWN
<br />Z Nebraska Sherman Loup City
<br />LL 8d. STREET AND NUMBER 9e. APT. NO. 8f. Z1P CODE 8g. INSIDE CITY LIMITS
<br />� 900 Hwy 92 68853 � v�s ❑ No
<br />.� 10a. MARITAL STATUS AT TIMH OF DEATH Q Married ❑ Never Marrted 10b. NAME OF SPOUSE (First, Middle, Last, Sufflx) If wBe, give malden name
<br />� p nnem.a but separated � Hnaowea ❑ orio►�aa ❑ Unknown Carmen D Mills
<br />� 11. FATHER'S•NAME (Flrst, Mlddla, Last, Suffiu) 12. MOTHER'3-NAME (Flrst, Middle, Malden Sumame)
<br />� Fri� Schwaderer Anna Holzerland
<br />Q ' 13. EVER IN U.S. ARMED FORCES? Give dates of servlce B Yae. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />$ (res, No, o� unk.� Yes 09/14/1956-09/13/1960 Darci Schwaderer Daughter
<br />,� 15. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 16b. UCENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ Buriai ❑ Donatlon
<br />Not Embalmed January 12, 2011
<br />� Cremadon ❑ Entombment 76d. CEMETERY, CREMATqRY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Specifyr)
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, CKy or Town, State) 17b. Zlp Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Isiand, Nebraska 68801
<br />CAUSE OF DEATH See Instructlons and exam les
<br />1d PART 1. F�ter the eba�n of evenm. �disaasea, InJuries, or wmpilcadone�that dlrectly causetl the death. DO NOT eMer terminal eveMs auch ae cardiac artest, ; AppROXIMATE INTERVAL
<br />respirstoyartest, or veMricuiar Bbriliadon wkhout shovring the eUology. DO NOT ABBREVIATE. Eirter only o�re muse on a Ilne. Atltl atltlnional Ilnae Ii nacassary.
<br />IMMEDIATE CAUSE: � onset to death
<br />IMMEDIATE CAUSE (Flnal a) Cholecystitis ; One Month
<br />dlaease or contlitlon reaulUng �
<br />m aeech) DUE TO, OR AS A CONSEQUENCE OF: ; onaet to death
<br />S�queMially Ilat conditions, ff b) '�
<br />arry, teatling to tha cause ilatetl '
<br />on U�re a �
<br />DUE TQ OR AS A CONSEQUENCE OF: ; onset to death
<br />EMer the UNDERLYINO CAUBE ��
<br />(disea� or In1�Y that Initlated �
<br />Uie eve�ta resuldne In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />� d)
<br />18. PART II.OTHER SIGNIFlCANT CONDITIONS-CorMitlo� contributl� W the death but not resuttlng In tha undarlying cause given In PART I. 18. WAS MEDICAL EXAMINER
<br />Chronic obstructive pulmonary disease, Coronary Artery Disease OR CORONER CONTACTED?
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />lL
<br />� � Not pre8�twithln Past yeaz � Natural � Homlcide � DHvedOperetor ��S � NO
<br />� � Pre9�ant etUme Mdeat4 . � pcaldeM � Pending Inveatlgadon ❑ Pe�O�
<br />T � NOt pregna�rt, but pregnant withln 42 daye of death � pedeau�a„ 21d. WERE AUTOPSY FINDINGS�AVAILABLE
<br />a � Sulclae � Cowd nat be detemuned ❑ TO COMPLETE CAUSE OF DEATHI
<br />� ❑ nia a�esnam. n�e aree�em as aaye w � yeer berore d•a�n omar lsaBCitr)
<br />� Q unknown H pregnam wtthin the past year ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, tarm, street, factory, offlce building, conatructlon slte, et4• (Specify)
<br />t�
<br />� ZZd. INJURY AT WORK7 22e. DESCWBE HOW INJURY OCCURRED
<br />�
<br />❑ YES ❑ NO
<br />22L LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OY DEATH (Mo., Day, Yr.) ��� 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� � Janua 10, 2011
<br />� � 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ° 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />���>
<br />� � Z Janua 11, 2011 10:50 PM � 4��
<br />�� � . To the heat of my Imowledge, death occurted at the Ume, data and place $ � 24e, On the 6asi8 0( examinatlon and/or i
<br />and tlue to the cauae(s) efated. (8lgnatura and TIUe) � the tlrtre, date antl iace antl due to th� ��on, ip my oplNOn deatA occurtad at
<br />F� o& � p uae(s) atated. (Slgnature entl Tifle)
<br />Travis S. Hageman, MD '' � g
<br />25: DID TOBACCO USE CONTRIBUTE TO THE DEATHI 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />� YES � NO � PROBABLY � UNFWOWN � YES � NO Not Appllca6la ff 26a is NO C] YES � NO
<br />2, E, TITL D ADDRESS O ERTIFI R SIC , HYSIC ASSIST T, RO R P IAN OR COU TY A O ) ype or Print)
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />ZSa. REGISTRAR'S SIONATURE �- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 13, 2011
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