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<br />STATE OF NEBRASKA
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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 OF ISSUANCE
<br />3/2/2020
<br />UNCOLN, NEBRASKA
<br />dY
<br />E
<br />202001$74
<br />MLA /630(4Q4,4*
<br />SARAH BOHNENKAMP
<br />ne-
<br />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 />1. DECEDENTS.NAME (First, Middle, Last, Suffix)
<br />Olga A Sweet
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Cedar Rapids, Nebraska
<br />T. SOCIAL SECURITY NUMBER
<br />507-36,2635
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />85
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />2108 W 10th St
<br />Sc. CITY OR TOWN OF DEATH (include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2108.W 10th St
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ba. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />o ER/Ou patient
<br />o DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />20 02486
<br />3. DATE OF DEATH (Mo., Day, Yr j
<br />February 26, 2020
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />April 18, 1934
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />❑ HOapiee Facility
<br />9g. INSIDE CITY UNITS
<br />res ❑ rso
<br />10bNAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Arthur Dale Sweet
<br />41. FATHER'S.HAME (First, Middle, Last, Suffix)
<br />Charles A Petersen
<br />13. EVER IN U.S- ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />14a. INFORMANT -NAME
<br />Karl Sweet
<br />12. MOTHER'S -NAME (First,
<br />Alverez F Konert
<br />Middle, Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />0 Burial 0 Donation
<br />®j Cremation ['Entombment
<br />❑'Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />16b. LICENSE NO.
<br />CITY /TOWN
<br />Grand Island
<br />16e. DATE (Mo., Day, Yr.)
<br />February 27, 2020
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />17b. Zip Code
<br />68803
<br />CAUSE OF DEATH (See Instructions and examples)
<br />1S. PART I. Enter the chain of events- diseases, injuries, or complications4het directly caused the death. DO NOT enter terminal 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 />aMEDIATECAUSE (Final : a) Cardiopulmonary Failure
<br />disease *sandhi* resulting
<br />in death)
<br />Sequentially list conditions, if
<br />any, leading to the cause listed
<br />on lbw..
<br />Enter t a UNDERLYING CAUSE
<br />(diesel* er Injury Mat Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Ovarian Cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />20 Minutes
<br />onset to death
<br />5 Years
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d►
<br />18. PART It. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF FEMALE:..
<br />❑ Net Pregnant whhin poorer
<br />0 Pregnant a line deem*
<br />❑ Net pregnant, but pragnent within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />El Unknown if pregnant within the put year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />21a. MANNER OF DEATH
<br />Nature ❑ Homicide
<br />0 Accident ❑Pending Investigetian
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF IN
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />2f. LOCATION OF INJURY STREETS NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />B w February 26, 2020
<br />> 23b. DATE SIGNED (Mo., Day, Yr.)
<br />8
<br />B'
<br />February 26, 2020
<br />23e. TIME OF DEATH
<br />05:17 AM
<br />29d<To the beet of my knowledge, death occurred at the time, date and place
<br />and due to the csuseis) stated. (Signature and Title)
<br />David Crockett, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ® NO 0 PROBABLY 0 UNKNOWN
<br />21b, IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />Passenger
<br />0 Pedestrian
<br />o Other (Specify)
<br />onset to death
<br />19. WAS MEDICALMUMMER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />URY.At home, farm, street, factory, office building, construction site, etc, (Specify)
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />I I I, 24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />igig
<br />a
<br />ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />21s. Gn the basic of examination and/or investigation, in my opinion Math occurred at
<br />the tete, date and place and due to the au els) stated. (Signature and Title)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />David Crockett, MD, 2620 W Faidley Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />)a4 -4a...17 �a� ✓tie.?. ri t
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) 14.0
<br />I
<br />February 27, 2020
<br />
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