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• STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE SEP 2 LINCOLN, I 2007 201305016 TANbEYS. ASSISTANT Art REOISTRAFR' NEBRASKA (or", HEALTH -AM) OMAN S ERVIG�sS STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 'FIPIANCE ANC SUPP CERTIFICATE OF DEATH = - U l . ;29 793 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) ; a Kenneth Larry Schwieger -k E5 ': M@IE - 3 .DATE•O EATH(Mo.- Day,Yr.) 4eptenitierk 2007 To Be Completedlvedfied by: FUNERAL DIRECTOR 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH ", Nebraska 5a. AGE -Last Birthday (Yrs.) 69 5b. UNDER 't YEAR ''Sc.,U11fIO21 DA,Y ATE.F E;1i=1TH (Mo:, Day, Yr.) i . February 22, 1938 MOS. DAYS ' r HOUfIS. Milt. ' 7. SOCIAL SECURITY NUMBER 506 -42 -4214 Ba. PLACE OF DEATH HOSPITAL: ❑ Inpatient QTHE13 ❑ NursingHome/LTC ❑ Hospice Facility 8b. FACILITY -NAME (It not institution. give street and number) 582 E. 18th ❑ ER /Outpatient ® Decedent's Home ❑ rcA ❑ Other(Spedly) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 582 E. 18th 9e. APT. NO 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS Q YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH. al Married ❑ Never Marned ❑ Marned, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10u. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. Ja, inice E Sinner 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harry Henry Schwieger 12. MOTHER'S -NAME (First, Middle, Malden Surname) Mildred Johanna Thesenvitz 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (Yes, no, orunk.) No 14a. INFORMANT-NAME Janice Schwieger - 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION 50 Burial ❑ Donation ❑ Cremation ❑Entombment ❑ Removal ❑ Other (Specify) 16a. EM E SIGNATU , 16b. LICENSE NO. 1191 16c. DATE (Ma., Day, Yr. ) September 12, 2007 16d. CEMETERY, CRE RYOROTHERL ON CITY /TOWN STATE Westlawn Memorial Park Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street. City or Town, State) Livingston - Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 17b. Zip Code 68803 u CAUSE OF DEATH (See instructions and examples) 1 18. PART I. Enter the chain of eventg -- diseases, Injuries, or complications- -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, r APPROXIMATE INTERVAL I respiratory arrest. or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 1 IMMEDIATE CAUSE: I onset to death IMMEDIATECAUSE(Final X C 0 PP I disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: I onset deeih In death) ,�Q� f y� r I,, p 1 1( Sequentially list conditions, If �"r ( 0 c" ` � 0 � /; 1, % k ,S - ` , /` af f any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I onset td'death on lines. Enter the UNDERLYINGCAUSE (disease or 1n)ury that Initiated (C ) the events resulttng ii death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death LAST I (d) I I . 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 OR CORONER CONTACTED? $I YES O' NO Ipleted by: CERTIFIER 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 yearbefore death ❑ Unknown if pregnant within the past year 1 . MANNER OF DEATH )(Natural 0 Homicide ❑ Accident❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Osier (Speaty) . WAS AN AUTOPSY PERFORMED? I` ❑ YES NO 4' WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES C'NO y a. DATE OF INJURY (Mo., Day, Yr.) 41i. TIME OF INJURY m ?tic. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 'd.INJURYATWORK? /\. ❑ YES )NO 2(. DESCRIBE HOW INJURY OCCURRED t. LOCATION OF INJURY - STREET& NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE To be completed by Attending PHYSICIAN ONLY 'yea. DATE OF DEATH Mo., Da Yr.) 01 /0 8 ' / 7, , -e Z >- , a0z d= E� ;Z 5da. DATE SIGNED (Mo., Day, Yr.) Btb. TIME OF Q EATH m 3b. DATE SIGN 0(M 1 A p -3- ? c.TIME OFDEATH Z O5D... m lac. PRONOUNCED DEAD (Mo., Day, Yr.) &d :TIMEPRONOUNCEDDEAD m 23d. To the best my and d th ca date 1 w z 0 . owledge, death occur ed at the time, te and place � Z � . e(s) stated. (Signature and Title ) • a 0 0 - F Q U 0 / 1 r 0 Ile. On the basis of examination and /or investigation, in my opinion death occurred at Y the time, date and place and due to the cause(s) stated. (Signature and Title ) • 2 DID TOBACCO U ONTRIBUTE ( THE DEATH? ❑ ❑ PRO =ABLY ❑ UNKNOWN 26 � , HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES 0, NO 2 .WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO ? .N YES � TME.TLH EANDADDRESSOFCERTIF_IER (PHYSICIAN- CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pnntl T. Hageman, Physician, 729 . Custer Ave Grand TRlana. NE 681101 28a. REGISTRAR'S SIGNATURE 11 " di ,41 • 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) SEP 1 3 2007 • STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE SEP 2 LINCOLN, I 2007 201305016 TANbEYS. ASSISTANT Art REOISTRAFR' NEBRASKA (or", HEALTH -AM) OMAN S ERVIG�sS STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 'FIPIANCE ANC SUPP CERTIFICATE OF DEATH = - U l . ;29 793