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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AjVQ 4/41N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASR'14e`D T 4-11 ,F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOP ITA4� . � R� 1
<br />0_.D t A l• S .I 1
<br />DATE OF ISSUANCE
<br />• ,
<br />201901985 47 /LEY S. CDOPER
<br />7AVISTAKIr . 7i4T,( R�GISi+RAR
<br />ER•4Z2TME # ORME IJH AN h
<br />I 4 y SERVICES
<br />r I p •,t .'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES;" 7
<br />2013 CERTIFICATE OF DEATH t, ‘rt ;{ (�t�
<br />DEC 09 2013
<br />LINCOLN, NEBRASKA
<br />To Be CompletedNerified by: FUNERAL DIRECTOR
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Henry Melvin Schwartz
<br />2. SEX r ,
<br />Male
<br />‘.3. TE, Og Dtf`� Mtutr y,Yr.)
<br />Octobe in, 2013
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE -Last Birthday
<br />5b. UNDER 1 YEAR
<br />6c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Cairo, Nebraska
<br />(Yrs.)
<br />89
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 9, 1924
<br />7 IA C UMBER -
<br />606 22 6106
<br />8a. PLACE OF DEATH
<br />HOSPITAL' ❑X Inpatient OTHER' ❑ Nursing Home/LTC 0 Hospice Facility
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />Veterans Affairs Medical Center
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ Other(Specify)
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2103 W. State Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />E Yes 0 No
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated IE Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Cornelia Kreachbaum
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Otto Schwartz
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Alma Spiehs
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 09/29/1944-11/11/1946
<br />14a. INFORMANT -NAME
<br />Gary Gannon -
<br />14b. RELATIONSHIP TO DECEDENT
<br />Power of Attorney
<br />15. METHOD OF DISPOSITION
<br />®Burin ❑Donation
<br />16a. EMB MER -SIGNATURE ..-------,
<br />u.t ,.Q !fie i. �
<br />16b. LICENSE NO. �y
<br />/ 31 /
<br />18c. DATE (Mo., Day, Yr.)
<br />October 21, 2013
<br />❑Cremation El Entombment
<br />❑Removal ❑Other S
<br />1 r cify)
<br />1 d. CE ETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />To Be Completed by: CERTIFIER i_ J
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the glek ver4 -dt , intones. or complications• that directly caused the death. DO NOT enter terminal event, such as cardiac. arrest. '
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on • line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting a) c‘ 10cG, rY-�--��
<br />in death) U.�a�.., ,, CC� N G1 vc C
<br />seRROvINIATE INTERVAL
<br />c..= tc dcot!
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If NVQ-,,
<br />any, leading to the cause listed C b) CIC\ (�@ �� 1 ' �Z OS k `(" `(� t \A C Q,
<br />onset to death
<br />on line a. DUE TO, OR AS A SEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) )s ; t) \ ��R����
<br />injury initiated iC-L7
<br />onset to death
<br />(disease or that
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE O •onset
<br />LAST
<br />d) C�COCtQC'\
<br />�`
<br />G\�C �.Y1,��O.SC_
<br />to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contrlb ng to the death but not ulting in the underlying cause given in PART 1.
<br />Aa>,��� - oc) _‘
<br />11
<br />CA,Cs0CItc C)}Q:2\CtaCllvc 7 ",\tRnOC>K'��N�R�e- �1a0Ekt-S'4A.
<br />u_`
<br />19. WAS MEDICAL EXAMINER
<br />OR❑CORONERCONTACTED?YES NO
<br />JF'vi
<br />20. IF FEMALE:
<br />❑Not pregnant within past year"�,�tural
<br />21a. MANNER EATH f
<br />❑ Homicide
<br />21b. IF TRANSPORTATION IMNJURY
<br />❑ Driver/Operator
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NIRNO
<br />['Pregnant at time of death
<br />❑Not pregnant, but pregnant within 42 days of death
<br />['Not pregnant, but pregnant 43 days to 1 year before death
<br />['Unknown if pregnant within the past year
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />❑ Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c, PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT' WORK"? 1 22e. DESCRIBE HOW INJURY OCCURRED
<br />❑YES 0 N
<br />I
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />d
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CC�O\1J�C 1 4 a.� 1.11
<br />l'` `
<br />Z
<br />a u z
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />.s i-
<br />d�
<br />Ego
<br />23b. DATE SIGNED (Mo., Day Yr.)
<br />ll
<br />�<I\b YC c�1C11�
<br />23c. TIME OF DEATH
<br />)0. 0 U.m
<br />d } 0
<br />F Y
<br />oN o
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />yU 23d. To the best of my knows d eath occurred at the time, date and place
<br />o W , an due to the Eau ) rated. ( ig� urs fid Title) I
<br />u W z
<br />a Q 78
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCq...USE C6NNTRIBUTE TO THeDEATH? __"..__-
<br />0 YES �p �0 ❑ PROBABLY ❑ UNKNOWN
<br />-28a. HAS ORGAN OR .. ION BEEN CONSIDERED?
<br />❑ YES !1 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES r 11i t,0
<br />T \
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />c�. '"&1\( ,\eW \- . . \I Nn_ (-9, c)l md)..)e11 (4c\r6
<br />-T.510,nd NOb`n,c, 0 8203
<br />P
<br />28a. R�cISTRAR'S SIGNATURE
<br />��/ 4
<br />(
<br />. ''
<br />28b. DATE FILED BY REGISTRAR (Mo., Day. Yr.)
<br />OCT 24 2013
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