|
�;(1iAll;%<lidMalil➢311`ID11,a15GnblifReikikM147Mao. Ait n 5\\ nit illiiiiiiil k1/21 \ .YITIY'P/
<br />1'a STATE OF NEBRASKA A
<br />Ebw. \Y@t':24YSt1i11�iVRIR3 Y6.'l'llbwt63 5 4:t171t1 \�ID@ < 6771GWi717AD.1!@ IN11 �gG�i��f �� �
<br />,x. :_-.::tiidx'I�r .:'s
<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 RECORD
<br />DATE OF ISSUANCE
<br />2/11/2020
<br />LINCOLN, NEBRASKA
<br />202003366
<br />uta,h &itnEnt
<br />SARAH BOHNENKAMP it
<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 />I2 SEX
<br />1. DECEDENTS -NAME first, Middle, Last, Suffix)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Istand, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-32-8363
<br />Sb. FACILITY -NAME (If not Instltutlon, give street and number)
<br />Wedgewood Care Center
<br />sc. crr. OF. ;OWN OF DEATH (Include Zip Code,
<br />S Grand Island 68803
<br />d
<br />1
<br />Bt
<br />m
<br />9a RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />2130 North Howard Ave
<br />9b. COUNTY
<br />Hall
<br />r5a. AGE - Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 DAY
<br />IYm) NOS.
<br />89
<br />20 01473'
<br />3. DATE OF DEATH -(Mo., Day, Yr.)
<br />9. DATE OF BIRTH (Mo„ Day, Yr.)
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />10a. MARITAL, STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />t..i Married, but separated ® Widowed ❑ Divorced 0 Unknown
<br />11. FATHERSNAME (First, Middle, Last, Suffix)
<br />Walter Schwieger
<br />ftc. CITY OR TOWN
<br />Grand island
<br />HOURS
<br />MINS.
<br />November 22, 1930
<br />I ❑ Hospice Facility
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Homs
<br />CI 'New (SPecNy)
<br />ed. COUNTY OF CEATH
<br />Hall
<br />}
<br />INSIDE Crit LIMITS'
<br />norm YES ❑ NO
<br />1011: NAME OF SPOUSE (First, Middle, Last, Suffik) N wife, give maiden na ne
<br />Naomi Arlene Wiley
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />12; MOTHER'S -NAME (First, Middle; Maiden Surname)
<br />Emma Knuth
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service N Yes.
<br />(Yes. No. or Unk.) No
<br />14a. INFORMANT -NAME
<br />Terry SChwieper
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METNOD OT DISPOSITION
<br />Burlal ❑ Donation
<br />❑ Cremation 0 En!en.t hent
<br />❑',Removal ❑Other(SpecHy)
<br />19a. EMBALMER -SIGNATURE
<br />Katie M. Smydra
<br />1$b. LICENSE NO.
<br />1454
<br />111c. DATE (Mo., Day, Yr.)
<br />February 7, 2020
<br />Ted. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />t17a, FUNERAL -HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />$ All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />A
<br />CAUSE OF DEATH (See Instructions: and examoleet
<br />CITY / TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />1713.73p Code
<br />68801
<br />• it. PART L E'n1K1b. VIVO of clients- -disease*, injuries, or camplicetlonedhat directly Maid tate death. DO NOT anter terminal aVnte such as cardiac sweet,
<br />• respiratory arrest orseatvpdar!IbrdYtlon without showing the etiology. DO NOT ASBROViATE. Either Orgy ay cava en a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IC IMMEDIATE CAUSE (Flail alAcute On Chronic Respiratory Failure
<br />Idisease or condition resulting
<br />in death)
<br />Pf417-1401.,.jl)cen'MIeN
<br />any, lesdln9 to ale cares Ila*ad
<br />A
<br />ffi
<br />A
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />~. C hfC i v V LJ.i M._w... • ^ MI�iNI �ul� l.:mar'..iSS
<br />APPROXIMATE INTERVAL
<br />onset to death '.
<br />Immediate
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE cl Chronic Systolic Heart Failure
<br />(dams or'NJurythat 10110ied,
<br />ttw.vents reeraiirw in *Oki
<br />LAO
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Pulmonary Hypertension
<br />onset to death
<br />Years
<br />onset to death
<br />Years
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART 1.
<br />Patient Transitioned To Hospice Care And Passed Away
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YEs NO
<br />20. IF FEMALE:
<br />❑ Na pregnant within put year
<br />0 Pregnant at time of death
<br />ID Nat pegnsnt but pregnant within 42 days or death
<br />❑ Not pregnant, but regnant 43 days to 1 year before death
<br />© unitlteam 5 pregnant within are pat year
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />❑ Accident 0 Pending Inveedgetion
<br />0 Suicide E3 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />QDriver/Operator
<br />0 Passenger
<br />© Pedestrian
<br />:❑
<br />Other ;Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES Q NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />IJ YES 0 N
<br />22b. TIME OF INJURY
<br />22e. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, eta (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ttr. LU\.A IRA yr Ilvdunr 81 nee I a nulaucn, Mr
<br />m E
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />January 30, 2020
<br />..,rurvnre
<br />23b. DATE -IRONED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />4 0'" January 31. 2020 07:38 AM
<br />123d. To the bat or my ImowIsdge, death occurred at the tame, date end place
<br />ana due to the camels) rand. (Slgnnras aria Title.
<br />MichaelA. Donner. MD
<br />25. DID TOBACCO. USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN
<br />24. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />24e. On the basis or examination andlor lnvestgrbn, In my opinion death miSyed at
<br />Me time, ate and place and due to the eausgp view t.iigninum 5.4 aim
<br />.14.1104.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Prim
<br />Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska,; 68803
<br />28b. WAS CONSENT GRANTED?:
<br />Not Applicable If 26a Is NO 0 YES 0 NO
<br />281. REGISTRAR'S SIGNATURE ri s
<br />28b. DATE FILED BY REGISTRAR
<br />February 6, 2020
<br />Mo., Day, Yr.) I
<br />
|