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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Everett Schwartz 2. SEX ; ` ", /1 ! , Male' " 3. DATE OF DEATH (Mo., Day, Yr.) ,January 3, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Cairo, Nebraska 5a. AGE - Last Birthday (Yrs.) 87 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) April 14, 1927 MOS. DAYS HOURS MINE. 7. SOCIAL SECURITY NUMBER 507 -24 -3944 8a. PLACE OF DEATH HOSPITAL J Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1324 N. Hancock 9e. APT. NO. 9f. ZIP CODE I 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH igl Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Marian McLellen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Otto Schwartz 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Elma Spiehs 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Constance Louise Gannon 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) January 7, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE Of DEATH (See instructions and examples) To be completed by: CERTIFIER I 11. PART I. Enter the chain of events - diseases, injuries, or complications -that directly caused the Math. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) Myocardial Infarction Weeks disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Coronary Artery Disease 1 Years any, leading to the cause listed I line on a. DUE TO, OR AS A CONSEQUENCE OF: : onset to death Enter the UNDERLYING CAUSE c) I (disease or Injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST d) 1 I • 18 PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I. Chronic Obstructive Pulmonary Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death J Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) January 3, 2015 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) 1 January 5, 2015 23c. TIME OF DEATH 06:50 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To INC best of my knowledge, death occurred at the time, date and plan and due to the cause(s) stated. (Signature and Title) Travis S. Hageman, MD 2N. On the basis of examination and/or investigation, In my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? I ❑ YES JJ NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER -(Type or Print Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 j2sa. REGISTRAR'S SIGNATURE S - - iO�V 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 7, 2015 DATE OF ISSUANCE 01/09/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH4A(fl I THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRAC HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V IA t I y . ` 5 2015(10824 ' S .� SPAR s� ► M Hlt1AN SERVIqS STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SeRt(fCgi CERTIFICATE OF DEATH Y `.a. 7 . f`SERVICES, IT CERTIFIES OF HEALTH AND