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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
<br />12/21/2020
<br />LINCOLN, NEBRASKA
<br />202100828
<br />11 I'VAL
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />20 18190
<br />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.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Leo Wiliam Schwieger Jr
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo;, Day, Yr.)
<br />December 10, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />84
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />January 28, 1936
<br />7. SOCIAL SECURITY NUMBER
<br />505_3$_6782
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC Hospice Facility
<br />8b. FACIUTY-NAME (If not Institution, give street and number)
<br />717 W Division Street, Apt. 1
<br />0 ER/Outpatient ® Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />717 W Division Street
<br />9e. APT. NO.
<br />1
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITYLIMtTS
<br />® YES Q 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 />Lana Marlene Christensen
<br />11. FATHER`S•NAME (First, Middle, Last, Suffix)
<br />Leo A Schwieger
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Evelyn Sophia Blase
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Lana Marlene Schwieger
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397
<br />16c. DATE (Mo., Day, Yr.)
<br />December 13, 2020
<br />Ea cremation 0 Entombment
<br />Removal ' 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. 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,
<br />APPROXIMATE INTERVAL
<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 />(*1MEDIATE CAUSE(Final a)Aspiration Pneumonia
<br />disease or condition resulting
<br />onset to death
<br />Weeks
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)Parkinsons
<br />any, leading to the cause listed
<br />online a.
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />(disease or Injury that Initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART IT. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL
<br />OR CORONER
<br />❑ YES
<br />EXAMINER
<br />CONTACTED?
<br />®NO
<br />20. IF
<br />0
<br />0
<br />FEMALE:
<br />Not pregnant within past year
<br />Pregnant stints of death:Passenger
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0Accident 0Ponding Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Oriver/Operator
<br />0
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑YES NO
<br />❑:Not pregnant, but pregnant within 42 days of death❑
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown H pregnant within the past year
<br />Suicide ❑Could not be determined
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY! FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a, DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc, (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES, ,❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />B
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 10, 2020
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COIN (Y ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />F
<br />Ifl
<br />), -23b.
<br />/
<br />DATE SIGNED (Mo., Day, Yr.)
<br />OECEDIDer 11, 2020
<br />23c. TIME OF DEATH
<br />04:09 AM
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />a"(
<br />8 o
<br />0 23d. To e boat of my knowledge, death occurred at the time, date and place
<br />thsue due to the cause(s) stated. (Signature and Title)
<br />Travis S. Hageman, MD
<br />24a, 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 Tale)
<br />25. DID -TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ® NO 0 PROBABLY 0 UNKNOWN
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES lia NO
<br />26b. WAS CONSENT GRANTED?:.
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />21. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue,
<br />Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATUREa�� �
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 17, 2020
<br />
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