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<br />WHEN 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
<br />DATE OFISSUANCE 202000004 RUSSELL FOSLER
<br />3/8/2019 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 />LINCOLN, NEBRASKA
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Donald Arthur Schwieger
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />75
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS..
<br />DAYS
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 22, 2019
<br />6. DATE OF BIRTH (Mo., Day. Yr.)
<br />December 27, 1943
<br />7. SOCIAL SECURITY NUMBER
<br />508.4.6-6385 ...
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Ediaewood Vista Grand Island
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />95. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9d. STREET AND NUMBER
<br />2505 Park Drive
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Arthur Frank Schwieger
<br />13 EVER IN U.S, ARMED FORCES? Give dates of service if Yes.
<br />(Yes, Na, or Link) No
<br />i5. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />❑ Cremation 0 Entombment
<br />Q Removal :❑ Qther(Specify)
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ERfOutpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (Specify)ASSISTED L.IV(NG
<br />Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE ;(First, Middle, Last, Suffix) If wife, give maiden name:
<br />Cheri Ann Sorensen
<br />12. MOTHER'S -NAME (First, Middle,
<br />Edna May Gosda
<br />14a. INFORMANT -NAME
<br />Cheri Ann Schwieger
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16b. LICENSE NO.
<br />1092
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />March 2, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Cemetery Grand Island
<br />STATE
<br />Nebraskd
<br />7a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska
<br />17b Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />S. PART I. Enter theshaln of events -.diseases, injuries, or complications -that directly caused the death. DO NOT entertenninel events such as cardiac arrest,
<br />reepiratory arrest, or ventdeyllr 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) Parkinson's Disease
<br />disease or cndkion resulting
<br />in death,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />4 1/2 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially 8n carnations, it >b)
<br />any, feeding to the Cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(lSaeaae or in•iury that inaieted
<br />the events rsstdthigan death)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death`
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />Parkinson's Dementia, Chronic Lymphocytic Leukemia, Hyperlipidemia, Depression
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ill NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />NOt pregnant, but pregnant: within 42 days of death Not pregnant, but pregnant' 43 days to 1 year before death
<br />0
<br />unknown a pregnant vdthint a past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident 0 Pending investigation
<br />0 Suicide ❑ Could not be determined
<br />21b, IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />Pedestrian
<br />OOther (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />CI YES ❑ NO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />[23e, DATE OF DPATH (Mo., Day, yr.)
<br />February 22,°2019
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />February 25. 2019 05:55 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Adam.Brosz. MD
<br />STATE
<br />24 DATE SIGNFD (Mo., Dar, Yr )
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26. Dip TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />El YES ® NO ❑ PROBABLY D UNKNOWN ❑
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Adam Brosz, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'SSiGNATURE , `F.
<br />26a. HAS ORGAN OR TISSUE OONATiON BEEN CONSIDERED?
<br />YES 7
<br />26b. WAS CONSENT GRANTED? :>
<br />Not Applicable if 26a is NO 0 YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR Mo., Day, Yr.)
<br />March 5, 2019
<br />
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