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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFJSSUANCE
<br />4/3/2023
<br />LINCOLN, NEBRASKA
<br />202:01923
<br />3€048,144,0
<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 />7 DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Ronald Eugene Schwab
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Junction City, Kansas
<br />T. SOCIA): SECURFTY.NUMBER
<br />p5-$2-7358
<br />Sb. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St, Francis
<br />8c -.CITY OR TOWN OF.DEATH (Include Zip Code)
<br />taeand Island 88803
<br />RESIDENCE -STATE
<br />ebraska
<br />9d. STREET AND NI MSER::
<br />2318 Stardust Lane
<br />9b. COUNTY
<br />Halt
<br />10a, MARITAL STATUS ATTIME OF DEATH ®'Married 0 Never Married
<br />Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />• FATHER S NAME (First, Middle, Last, Suffix)
<br />Merlyn Eugene Schwab
<br />13. EVER IN U41. ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk) No
<br />0
<br />v
<br />�15. METHOD OF DISPOSITION
<br />�:f3rLrfal ❑ Donation
<br />❑ Gremtttittti Entombment
<br />❑'Removal
<br />❑ Other (Specify)
<br />6a: AGE - Last>Mrthday::
<br />(Yrs.)
<br />63
<br />5b UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE O! DEATII
<br />HOSPITAL ®lnpattent
<br />❑ ER)Ou patient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 04108
<br />3. DATE OF DEATH (Ma, Day Yr.)
<br />March21, 2023
<br />6. DATE OF BIRTH:4Mo., Day, Vt.)
<br />October 2.2, 1959
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Halt
<br />© Hospice Feofftty•
<br />9f. ZIP CODE
<br />68803
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Susan Busch
<br />Sg INSIDE CITY LIMITS
<br />I YES O No
<br />14a. INFORMANT -NAME
<br />Susan Schwab
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />12. MOTHER'S -NAME (First, Middle,
<br />Marv: Margaret Keehn
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION
<br />St. Mary's Cemetery
<br />L 17a FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Rasmussen Mortuary, 311 Grand Avenue, Ravenna, Nebraska'"
<br />18b. LICENSE NO.
<br />1191
<br />CITY / TOWN
<br />Pleasanton
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT`
<br />Wife
<br />16c. DATE (Mo„, Day, Yr.)
<br />March 25 2023 :<
<br />Nebraska
<br />17b. Zip Cods
<br />68869<
<br />ECAUSE OF DEATH (See instrucd'ont3 and examples)
<br />111. PART I. Enter the chain of events- 41seeaes, Injuries, or complication -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />re
<br />u
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines it necessary.
<br />immeoi TE CAUSE(Flttat
<br />demos or rwndttlon resulting
<br />Sequentially bet conditions, If
<br />any, Raping to the bauaa::Neted
<br />Ene..rhe UNDEL NOCASE.
<br />.
<br />(dlseaes or injury:first Inttleteri
<br />the events resulting In death)
<br />LAST
<br />E
<br />IMMEDIATE CAUSE:
<br />a) Cardiogenic shock
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) heart failure
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATE INTERVAL
<br />onset to deatlf>
<br />1 Day,;
<br />onset to death
<br />5 Years
<br />18
<br />PART:tri. orNENNIONNIcANT CONDITIONS -Conditions contributing to the death but not; resulting Irl theunderlying cause given in PART I.
<br />evere Sorticistenosis, chronic systolic heart failure,persistent atrial fibriliation,peer compiiancewith medications and follow up
<br />20. IF;FEMALE:...
<br />Not pregnant within past;year
<br />Pregnant at tai!le of rloath
<br />Nat pregnant,: but pragnsnf wxhin 42 days of death
<br />No pregnant,: but pregnant 43 days to 1 year before death
<br />Unknown tt trirsm M within the peel year
<br />t2a )')ATE OF INJURY (Mo.i Day, Yr.)
<br />122d. INJURY AT WORK?
<br />❑YES 0 NO
<br />21a. MANNER OF DEATH
<br />® Natural. ©Hom[eide
<br />0 Accident "1"
<br />vesiigatlon
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21;b.IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />Q Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />19. WAS MEDJCAI,,EXAMINER
<br />,
<br />OR CORONER CONTACTED?
<br />® YES O NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES J NO
<br />21d. WERE AUTOPSY FINDINGS A'VAILABL'E
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ONO
<br />22c. PLACE t7F INJURY. At home. farm, street,' factory, office building, construction site, etc.
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CATION OF INJURY STREET & NUMBER, APT.NO.
<br />g
<br />23a. DATE OP DEATH (Mo., Day, Yr.)
<br />March 21, 2023
<br />CITY/TOWN'
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 23, 2023
<br />23c. TIME OF DEATH
<br />12:42 PM
<br />23d, TE tip! boat Of my knowledge,tluth occurred at the time, date and place
<br />and due to the aeusMa) stated (signature and Tide)
<br />Srikanth Reddy Kothapalli. MD
<br />iguitlgt
<br />STATE
<br />24k DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />psaiiy)r;
<br />P CODE_.
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />345.dial e basis of examination andlor investigation, In my opinion Matt Ot:Cimed at
<br />. _ tee time, dare and place and due to the causes) stated. (Signature antkEds)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES 0 NO PROBABLY ® UNKNOWN
<br />27. NME, TITLE AND AD;. ESS OF CERTIFIER (Type or Print
<br />Srikanth Reddy Kothapalli, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 285 Is NO 0 YES
<br />❑ NO>
<br />128a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 29, 2023
<br />i
<br />CD
<br />00
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