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<br />COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />COPY OF THE ORIGINAL RECORD ON FILE WITH ThE NEBRASKA DEPARTMENT OF HEALTH AND
<br />V►TALRECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />l�eatt4Mi�rr/NAn4» t�ll�1).11(II�frI�Lfrd4tlaTVnt�A)i ��litVe6iG,a�
<br />L.4-- STATE OF NEBRASKA
<br />r6irr mobttaos '4.9 i9N1gm y$
<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 />CERTIFICATE OF DEATH
<br />DECEDENT S NAME f Ftrat, Mt
<br />i cry
<br />ice) tirIIT Sufllvan
<br />A. +CITY AND STATE OR' TERRITORY,' OR FOREIGN COUNTRY OF BIRTH
<br />Fia€tin.9tont Nebraska
<br />SOCIAL SECURITY NUMBER
<br />5 8 52=39t7
<br />5b UHCER 1 YEAR
<br />2. SEX
<br />Male
<br />22 04117
<br />3. DATE OF DEATE (Mo., pay Yr )
<br />Mart! 10,1)22
<br />Sc. UNDER 1 DAY
<br />2816. B€entvood B.t
<br />Sc<.C(TY OR TOWN'OF
<br />...................................... .
<br />........................................
<br />Grand Island 688
<br />9a. RESIDENCE STATE
<br />83. PLACE OF DEATH
<br />daC TA`At Q Inpatent
<br />❑ ER/Outpatient
<br />DOA
<br />°TAM ❑ Swaim He 1.76V7 "1
<br />® Decedenrs Worse
<br />0 Other (Spaeify)
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d.'o BEET AND NUaIBER
<br />2815 Brentwood Blvd
<br />10a MARITAL STATUS AT TIME OF DEATH IX_I Married ❑ Never Married
<br />0 Married, but separated ❑Widowed 0 Divorced 0 Unknown
<br />Last, Suffix)
<br />t3. EVER iN U;S, ARMED -FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />1 S. AAETHOD OF DISPOSITION
<br />.. O' Burial I) Donat(on
<br />•
<br />Crumettom ❑ Entogeo meat
<br />O Remi ova ' ❑other(specify)
<br />Pe. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />10b. NAME (3F SPOUSE (First, Middle, Last, Suffix) If wife, give maiden amino
<br />Myrna J Schwiesow
<br />11Z MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Clara F Miller
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />16b. LICENSE NO.
<br />1448
<br />14b. RELA110P TO DteGE ENT'
<br />Spouse
<br />16c. DATE (Mo, Dtty,:Yr )
<br />March 16,<:2022
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />7a .:F ,)NERAL:HOMB.:NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Apfei Funeral Ho , 1123 W. 2nd, Grand Island. Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />PART I. Enter the chain of events- -camases, Injuries, or compllcatlonsehat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, eswtmieuter tauMteaorrwanaut showing ere etiology. l.0 Nt:T nt38nGY.A i E. Enter only one cause on a line. Add additions: lines If ne.eeee.y.
<br />IMMEDIATE CAUSE:
<br />iMMimiestBAfes6 (Pali a). respiratory failure
<br />alae ase w esnitkton resuxlnE:
<br />Sequentially list conditions, if
<br />etw, haeing to the cause :Mad
<br />oMei,'
<br />........." .............
<br />.................................:.......
<br />......................................
<br />tiie ;th PIO$f OWli'CA)
<br />(citeeaseorhyuryiba(nt etio
<br />the everts resetting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) COPD
<br />IF:FEMALE <>
<br />1 41ot p! agnea t yrRlNi pats
<br />Pregnant#eMe Of 4eath Y.
<br />C1
<br />❑ ilat tw4gnaiiir but pna9dere within 42 days of death
<br />Not pregnant, bid pregnant 43 days to 1 year before death
<br />❑:t(rlkhoeariri+reaasotw#hknthe past
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending ltweelIgation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF. TRANSPORTATION
<br />Driver/Operator
<br />Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />INJURY
<br />19. WAS MEO1CA(EXAMII ER.:.
<br />OR CORONERCONTACTED?
<br />❑, ]
<br />21c. WAS AN AUTQfklY PERFORMED?
<br />❑ YES
<br />E
<br />i6 PART IL OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting: in the underlying cause given in PART I.
<br />22c. PLACE OF INJURY At home,; farm; street, factory, office building, construction Site, Malt. (Specify)
<br />INJURY ATWORK
<br />❑YES ❑NO',
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />AflO (?P#NJURY STREET& NUMBER, APT.NO.
<br />EA (1E0., Day, Yr.)
<br />0, 2022
<br />CITY►TOWN STATE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD.:..
<br />lie death Occurred at the time, date and place
<br />aad. (Signature and Title)
<br />Gn the) eis of examination andlor investigation, in myopinton death Mitred et
<br />?w ttme date and place and due laths causal.) stated. (Signature $m1 T1s)
<br />26a. HAS ORGAN OR TISSIJE DONATION BEEN CONSIDERED?
<br />❑ YES
<br />SECONTRIBUTE TO THE DEATH?
<br />ICI PROBABLY 0 UNKNOWN
<br />A DRESS OF CERTIFIER (Type or Print
<br />MiO, 729 North.Custer Avenue, PO Box 2339,•Gram• - _ ebreska, 68803
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 20, 2022
<br />
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