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STATE OF NEBRASKA WHEN !! THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT 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 1S THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 1/16/2018 LINCOLN, NEBRASKA 201802912. HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ronald Lee Schwieger 4, CITY " AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH North Platte, Nebraska 7. SOCIAL SECURITY NUMBER 508-40 -0639 re 8b. FACILITY - NAME (If not Institution, give street and number) v • CHI Health St. Francis ce 8c. CITY OR TOWN OF DEATH (Include Zip Code) • Grand Island 68803 < 9a. RESIDENCE -STATE w Nebraska E 9d. STREET AND NUMBER ,, 3990 W. Capital Ave. a Ts 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married et if, ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown B 11. FATHER'S -NAME (First, Middle, Last, Suffix) d Donald Schwieger E 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. v (Yes, No, or kink.) Yes 06/06/1956- 05/10/1958 0 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal !❑ Other (Specify) 0. O a , in death) Sequentially listcondihons, if any, teadmg to the cause listed on line ti 20.IFFEMALE: ❑ Not pregnant past year W ❑ Pregnant at time of death U ❑ Not pregnant,fbut pregnant within 42 days of death ❑ Not pregnent, but pregnaiM 43 days to 1 year before death © unknown if Pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) December 26, 2017 22d, INJURY AT WORK? OYES p NO a �W s E w J E O Z u O 2 u o 23a. DATE OF DEATH (Mo., Day, Yr.) January 6.2018 23b. DATE BI ED (Mo., Day, Yr.) January 9, 2018 25, DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES 15E1 NO ❑ PROBABLY ❑ UNKNOWN 5a, AGE - Last Birthday (Yrs.) 80 9b. COUNTY Hall M OS. 16a. EMBALMER- SIGNATURE Not Embalmed 5b. UNDER 1 YEAR DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS 9e. APT. NO. 121 MINS. 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska 9f. ZIP CODE 68803 14a. INFORMANT -NAME Dorothy Elaine Schwieger 16b. LICENSE NO. 3. DATE OF DEATH (Mo., Day, Yr.) January 6, 2018 6. DATE OF BIRTH (Mo,, Day, Yr.) October 3, 1937 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 9g. INSIDE CETY LIMITS '' ® YES ❑ NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Dorothy Elaine Roe 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Junetta Meintken 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) January 11, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17b. 7Jp Code 68801 • CAUSE OF DEATH (See instructions and examples) APPROXIMATE INTERVAL onset to death 11 Days 8. PART I. Emerthe chaihof events- -diseases, injuries, or complications -that directly caused the death. 1)0 NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVfATE. Enter only one pause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) T12 Fracture disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: b) Fall onset! [o death 11 Days DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) {disease or injury beat initiated onset to death the tt ents renal re in death) DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART ti. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Chronic Systolic CfIF,Chronic Respiratory Failure, COPD, Stage 3 Chronic Kidney Disease, Permanent Atrial Fibrillation, Diabetea Mellitus Type 2 onse 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? DYES ! ® NO ; 22b. TIME OF INJURY 07:00 AM 21a. MANNER OF DEATH ❑ Natural ❑ Homicide El Accident ❑ Pending Investigation ❑ Suicide ❑ Could be determined 21b. IF TRANSPORTATION INJURY Driver /Operator ❑ Passenger Pedestrian El Other (Specify) 21c. WAS AN AUTOPSYiPERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ ND 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) Nursing Home 22e. DESCRIBE HOW INJURY OCCURRED Walking to sink to refill water, fell onto low back 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. 3990 W Capital Ave, Grand Island CITY/TOWN STATE Nebraska ZIP CODE 68803 23c. TIME OF DEATH 10:15 AM 2 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Adam Brost, MD 28a. REGISTRAR'S SIB NA 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE II DONATION BEEN CONSIDERED? ❑ YES ® 24e. 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) 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Adam Srosz, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 28b. DATE FILED BY REGISTRAR (Mon Day, Yr,) January 11, 2018