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<br />WHEN i. THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS f,
<br />J
<br />DATE OF ISSUANCE RUSSELL FOSLER
<br />11/27/2019 201907763 ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />UNCOLN, NEBRASKA
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />James Douglas Swiatoviak
<br />4.: CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-74-5769
<br />5a. AGE - Last 8lrthday
<br />(Yrs.)
<br />65 I'
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />Good Samaritan Society -Grand Island Village
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />48 Kuester Lake
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day,Yr.)
<br />November 17, 2019
<br />8. DATE OF BIRTH (Mn., Day, Yr:),
<br />June 20, 1954
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />0 Hospice Facility
<br />8g. INSIDE CnY Lintas
<br />❑ YES ® NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑'Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Lauren Edifier
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Leon W Swiatoviak
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Geneva L Morris
<br />13. EVER IN U.S,;ARMED :FORCES? Give dates of service if Yes.
<br />(Yee, No, or Unk.) NO
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />Cremation 0 Entombment
<br />0 Removal ❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Lauren Swiatoviak
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />PART 1. Enter the chin of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enterterminai events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Uroepithelial Cancer
<br />disease or condition resulting
<br />zIn death):
<br />Sequentially est conditions if
<br />ant. feeding to the cause listed
<br />on Tins It
<br />Enter the UNDERLYING CAUSE
<br />(disease or It jury *hat initiated.
<br />the events refultiS in death)
<br />LAST'
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF -FEMALE:
<br />0 Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant._ but pregnant 43 days tol year before death
<br />❑ :Unknown if Pregnant within the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />D Other (Specify)
<br />14b. RELATIONSHIP, TO DECEDENT..
<br />Spouse
<br />16c. DATE (Mo„ Day, Yr.)
<br />November 18, 2019
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INT£RVAo,
<br />onset to(death
<br />6 Months
<br />onset to death
<br />onset
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?I
<br />lid YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATh?
<br />0 YES 0 NO
<br />22c. PLACE OFINJURY-At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET 8, NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />OZ
<br />02
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 17, 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 18 2019
<br />23c. TIME OF DEATH
<br />08:15 PM
<br />3d. To the best of my knowledge, death occurred at the time, date end place
<br />anddue to the cause(s) stated. (Signature and Title)
<br />Gary Settle, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES blJ NO 0 PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR
<br />0 YESIll NO
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />Ste. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the camels) stated. (Signature and Tent)
<br />TISSUE • ATION BEEN CONSIDERED?
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑'YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Gafy Settle, MD, 2.116 W Faidley #400, Box 9802, Grand Island,
<br />28a. REGISTRAR'S SIGNATURE
<br />X68803
<br />28b. DATE FILED BY REGISTRAR
<br />November 22, 2019
<br />i
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