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1. DECEDENT -NA1AE FIRST MIDd:E LAST ceOrge William 2. SEX a DAIS OF DEATH :M4ya 0M. VW ? . 1 DAY I OA . KW AtTr sB2f 7d, 1404 taw AND STATE OF MATH aorn U.S.A. mint eonayl p��'A�+� t~ 140' S SW1ay ens.1 74 1 YEAR Sb. MOB. 1 OATS Sc HOA S • 41//6. T. N i 90GK SECU 506 30 7429 as PLACE OF DEATH Hoserrat.: 0 inasysa OTHER 1.1 ■ ER Woos* ❑ DOA ■ Nosing No., IWOmOa OWO wF"' ID FACILITY - Nara 111 Ini41A0ApAm...N7anont.I10.D 209 West 20th Street Pc CITY. TOWN OR LOCATION OF DEATH 1 44. INSbE CRY EARS Grand Island I Y« a No ■ .a COUNTY OF DEATM Hall as RESIOENC5 -STATE Nebraska 10. RACE - M4- WAN. Sl*& AROMAS .ICI.ISO.C11yI White 14. USUALOOCUSATION Ow IR COUNTY Wan. ll 11. ANCESTRY at. OWL ns *Mg most 4eie.n. . ac. CITY. TOWN OR LOCATION 'Grand T.l a yr3 , - - .N1 12 ® MIMED igan • raw KIND OF B INDUSTRY a4. STREET 2l9 in n NIDOWW °"wiC ARO NUMBER SaamOtaNCLaw fit a $'- I KRA411 1a OF SPOUSE Oak a aawar•AaR.F ° C warm 15. EOUC11TION IONS ?VON SONNlw4al4MA amostarnaiNS "" el "0 m Masiinalraew • at dwlk.lplaA wmnlrY.4f Teacher Education Y ar 12020207 10.1 4 r4' 1 it FATHER -NAME FIRST MIDDLE LAST William NMI Swartz 17. MOTHER i1R8T 1S0DLE itliMeitiONFAIE Rose NMI Riek 10 WAS DECEASED Nu. no. 0114 Yes EVER 1N U.S. ARMED FORCES? 1 11/ yaa one wt Wd Ms d wakes) I 60 51 -6/11 /53 Korea 19a INFORMANT - NAME fns CTATart7 120. INFORMANT A DDRESS (STREET OR 01 NO.. CRY OR TOWN. STATE. DP) 209 West 20th Street, Grand Is , Nebraska 68801 20. E = _- TURF 5 LICENSE N0. :P , p AI ioq 7 210 METHOD OF 064081T104 ❑ aura ❑ R >d ] °i ""' °n ❑ Do "° 210 DATE Mar. 22, 2000 21c. CEMETERY ORCRE.IATOR+ WYE Central NE Cremation Servi 214. C IETERYOR 0SESM005Y IACAT.ON are ORt 1 Gibbon, Nebraska 220 F .• HOME• - Kleine Fureral Home 220. FUNERAL HOME ADDRESS (STREET OR RF.D. NO.. CITY OR TOWN. STATIL DPI 3213 W. North Front St ( _ :1 anrI a $1C Q3 P511 L1 OR jai. t D Java' awalia 23 MILIEOIATE CAUSE F � NEECAL1S PART DUE TO, OR AS A CONSEOUENCE OF 9t9•.a/tolooso oraloodruar OS ./� 3 J 9 ?�T DUE TO. OR AS A CONNMEOUENCE OF (eI arrwtlwwRaam�a• p b or dean AS MOW PART OTHER S1ONIFICANT CONDIT10NS . Cartons ccorYAn W PART 91 4 FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MCNTHr Oros 1D.341 Yes ❑ No ❑ 44 ACR0PSY Vat ❑ No 25. WAS CASE ISIAINIER ORCOPONERT -` 74a ❑ 1M 4^ ---` 2w ❑ LlocioNomord ❑ s1.a4F ❑ P.nyna ❑ NCmCb tunas oo. 250 DATE OF WRY RY yb Day 177 lac NOUR OF ASSAY 7 254. DESCOPE HOW INJURY OCCURRED f____ m we y 25. PuuRY AT WORK r 3 IN 447. W IN:4 Yoe D No ❑ ( dt 2 g LOCATION STREET 00 RF.D NO CITY OR TOWN STATE A11/0 NYIJ15ANd' 27. DATE OF DEATH Pao Day Yrt L Ally 1 A 3NN0UY AI M'€J u MI-ISAWI i ! N1 MMart3um 2So DATE SHINED Mb Day 11' I 3ab TOE OF WAIN 2Sc PRONOUNCED OF11D Mb Oar W 201. EA PRONOUNCED DD Roar Y 270 DATES 3NED ��140 0.o 7.1 ' / "C3 _' 77c TRW OF DEATH / / � . /yam M . .awala a1 ay wpm tam mama a SF Cr P9S SOON d.a.11P46 M R ama r RD yaw and a9. a M CMNN arm ' M oa 1StRao• WTI* P 274 To ar WO d or knowIrga atMYM. aft a *mains ' MAORI 11000. n4 aN4. ..__ nt *mains (Swam 9 Tea GY � _s-'• - - - .. 2a 010 TOBACCO USE CANT 0THE DEATH? . 1111 YE3 ❑ NO 30 a 11AS ORGAN OR T1SSUF DONATION BEEN ❑ ,r: O 300 WAS 0010111301 ONANTE0 ❑ YEa e -- 31 NAME AND ADDRESS OF CERTIFIER IPHYSICMN. CORONERS PHYSICIAN OR COU ATTORNEY. ITp/ Awl David L. Howe MD, 2115 N. , tings, Nebraska 68901 324 RECIISTRAR Ciallha'''.. 3120 OATS FIFO SY AE Iai),LYE M STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. i STANLEY SUCOOPER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES DATE OF ISSUANCE NOV 12 2009 LINCOLN, NEBRASKA 2013006 STATE OF NEBRASKA- MPARIEIE TOFHEALTHANDHUNANSERVICESFINANCE VITAL STATISTICS CERTIFICATE OF DEA1II 0 0 • Exhibit "A" 03571