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<br />_STATE OF NEBRASKA,
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<br />RRIES THE RAISED SEAL OF STATE OF NEBRASKA; IT CE TIFIES THE DOCUMENT BELOW TO
<br />8E 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
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<br />100,„
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<br />DATE OF ISSUANCE:.
<br />7f1 2{2023
<br />LINCOLN, NEBRASKA
<br />36kila SARAH BOHNENKAMP
<br />2023036 42- ADEPAR MENTOFHEALTHR
<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 />Eugene Andrew 'Swanson
<br />4. CITYAND STAVE OR,TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Garfield County, Nebraska
<br />7 SOCiA4 SECU)TY NUMBER
<br />506.32 $345
<br />5a. AGE - La
<br />(Yrs.)
<br />b. FACILITY -NAME ((f not Institution, give street and number)
<br />Community Memorial Health Center LTC
<br />8c CIT Y OR TOWN OF DEATH (Include Zip Code)
<br />Burwe)I 68823
<br />9a RESIOENCE43TATE
<br />Nebraska
<br />9d. STREET: AND::NUMBER.;;.
<br />482236 State Highway 91
<br />82
<br />Birthday
<br />Sir UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS. DAYS
<br />84. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />❑ ER/Ou patient
<br />0 DOA
<br />9b. COUNTY
<br />Garfield
<br />10a. MARITAL Value AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHERS -NAME (First, Middle, Last, Suffix)
<br />Roy: Andrew Swanson
<br />43. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) Yes 04/08/1952-04/08/1954
<br />15. METHOD OF DISPOSITION
<br />�I Burial ❑ Donation
<br />❑ Cremation Eittambtlent
<br />❑Removal ❑ Other (Specify)
<br />9c. CITY` OR TOWN
<br />Burwell
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATtf tMw Day, Y .
<br />December 3i20:12
<br />6. DATE OF FORTHIMO.,;Day.Y )
<br />20, ..1
<br />Au
<br />OTHER ® Nursing Horne/LT
<br />❑ Decedent's Hem
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Garfield
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68823
<br />90.001pe.CITII iOrrs:
<br />❑YES 1 NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Lois Morrow
<br />14a. INFORMANT -NAME
<br />Sheryl Koll
<br />18a. EMBALMER -SIGNATURE
<br />Allan L. Hitchcock
<br />12. MOTHER'S -NAME (First, Middle,
<br />Susan Peart Conner
<br />16d. CEMETERY, CREMATORY OR OTHER LOCA ION:
<br />Cottonwood Cemetery
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Hitehcook
<br />FleleraV'tionie,i Inc.; 212 Grand Avenue, PO Box 871, Burwell, Nebraska
<br />16b. LICENSE NO.
<br />1064
<br />CITY / TOWN
<br />Burwell
<br />Maiden Sumame)
<br />14b. RELATIONSNip.:':TO deceoENT
<br />Daughter
<br />16c. DATE (Mo., Day, Yr.)
<br />December I. 2012
<br />CAUSE OF DEATH (See lastructions '<and examolas)
<br />8. PART 1. Einer the t hair of svants• diseases, injuries, or complications -that directly caused the death. DO NOT enter tem(inal events such as cardiac arrest,
<br />spkatory arrest, or ventricular flbrlllation without showing the etiology. DC NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />venotAis,cAuseegthat al Acute Cerebral Vascular Accident
<br />meeasm pr a/AMBid0 tasuhing
<br />In dead DUE TO, OR AS A CONSEQUENCE OF:.
<br />Sequentially Het conditions, if b)Subdural Hematoma Due To Stroke In 2011
<br />any, leading to the cause listed
<br />Online, .....
<br />$rater the UND RLyirva CAU. E
<br />(disease orlajury tits* 7nidatgd :.
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />c) Hypertension
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />IAST d)
<br />18. PART 11.
<br />OTHeR'SI
<br />JFtCANT CONDITIONS -Conditions contributing to the death but not resulting in 5*s underlying cause given In PART I.
<br />20. IF FEMALE:
<br />© NO pikglianl within pale year.
<br />❑ Pregnant at tithd Ot death
<br />Ndt pre9niint, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />D Unknown If pregnant within the past year.
<br />22d.
<br />4E OF INJURY (ML,;04y, Yr.)
<br />IIURY AT WORK?
<br />OYES 0 N
<br />21a. MANNER OF DEATH
<br />▪ Natural 0 Homicide
<br />O Accident 0 Pentlinganvesogatiop
<br />❑ Suicide ❑ Could not be tlete'Mined
<br />22b. TIME OF INJURY
<br />22c. PLACE:OF INJ.0
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221: LQQAT10N 0 INJURY :STREET & NUMBER, APT.NO.;
<br />z
<br />23a. DATEDF DEATH (Mo., Day, Yr)
<br />December 3, 2012
<br />21b. IF TRANSPORTATION INJURY
<br />❑: OdveriOparetor
<br />Di Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />i onset o tfiettr
<br />Years
<br />onset to death
<br />19. WAS MabIGALEXAMINER ;.
<br />ORCORONERf »4TACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®► ►
<br />21d. WERE AUTOPSY FINQINGSAVAALA r
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />-Athomefarm, street, factory, office building, construction
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />December 19. 2012 12:57 AM
<br />3d, To the..best dt my **ledge, death occurred at the One, date and place
<br />4nd due to the Cause(a) stated. (Signature and Title)
<br />Hugh R. Holmquist, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the iasia of examination and/or investigation, M my oplated death *e+Cu*Yadat
<br />t e Moe, date and place and due to the cause(,) stated. (Signature iISd)
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES el NO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />-[1YES NO © PROBABLY 0 UNKNOWN
<br />NAME, TITLED ADDRESS OF CERTIFIER (Type or Print
<br />HUgh R Holmquist, MD, 410 South 8th Ave., PO Box 906, Burwell, Nebraska, 68823
<br />28a. REGISTRAR'S SIGNATURE A+
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES ❑ NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 19, 2012
<br />
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