201902593 - Laserfiche WebLink

Browse

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 IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 3/14/2019 LINCOLN, NEBRASKA RUSSELL FOSLER 201902593 A DEPARTMENT OF IEALTHAR AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Pursuant to section. 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Gary Warren Swallow 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) March 8, 2019 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Des Moines, Iowa (Yrs.) 75 MOS. DAYS HOURS MINS. August 23, 1943 7. SOCIAL SECURITY NUMBER 485-50-0358 8a. PLACE OF DEATH HOSPITAL © Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility tib.. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatie•it ❑ Decedent's Home 0 DOA 0 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 4213 South Engleman Road 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS 0 YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Betty Casper 11. FATHER'S -NAME (First, Middle, Last, Suffix) Wayne Swallow 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lucille Reimann 13 EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unit.) No 14a. INFORMANT -NAME Amy Martinez 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Gwen K. Hyronemus 16b. LICENSE NO. 1448 16c. DATE (Mo., Day, Yr.) March 12, 2019 ® Cremation 0 Entombment 0 Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) i8.' PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. 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: IMMEDIATE CAUSE (Final a) Cardiac Arrest disease or condir,on resulting onset to death Minutes in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)Acidosis any, leading to the cause listed line onset to death Hours on a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Hypotension/Shock (disease or Injury that initiated onset to death Hours the events resuamg in death) DUE TO, OR AS A CONSEQUENCE OF: 1A T• d)Multi Factorial Cardiogenic With Septic onset to death Hours 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Acute Respiratory Distress Syndrome 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE: 0 Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑YES ® NO ❑ Not pregnant, but pregnant within 42 days of death❑ 0 Not pregnant, but pregnant 45 days to 1 year before death 0 Unknown if pregnant within the past year Suicide DCould not be determined Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 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 0 N 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 73a. DATE OF DEATH (Mo., Day, Yr.) March 8, 2019 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORIIEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) March 11, 2019 23c. TIME OF DEATH 03:59 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.1 24d. TIME PRONOUNCED DEAD 3d. To the best of my knowledge, death occurred at the time, date and place and due to the causes) stated. (Signature and Title) Zachary W. Meyer, MD 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ® NO 0 PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ISSUE I • ATION BEEN CONSIDERED? ❑ YES a NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Zachary W. Meyer, MD, 2116 W Faidley #400, Box 9802, Grand I • Nebraska, 68803 28a. REGISTRAR'S SIGNATURE 'fir ----- - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 12, 2019