|
/Iii/1111�Ni:"
<br />�Itlililll'IGI % fill `i1)tllililiil�4n rrr, i, V (111�IIIt1%�I j Li I ryi0111,411%,/! J.rd.]i 1 \1Q11�11111��1 „r
<br />r♦//I /1111111111ii:��� u � rrr MVt - //t/IIIIIIhDtV'`
<br />iti ��\11�I,II�jl�l/. al
<br />a 1YHEN 'i N1S COPY CARRIES THE RAI SED SEAL OF STATE OF NEBRASKA, IT fERIVIES THE DOCUMENT BELOr
<br />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 cW ISSUAN
<br />12/30/201>?
<br />LINCOLN, NEBRASKA
<br />202303974.
<br />MCA t
<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 />• D EI ENTS-NAM? (FIrst, Middle, Last, Suffix)
<br />Caro) Ann iiSiovititar
<br />4 CITY AND $TATE Of 'TERRITORY; OR FOREIGN COUNTRY OF BIRTH
<br />rural. Wolbach, :Nebraska
<br />7. 9CtA ;SEr"GIRI NIJMBER
<br />6054B -E °I86
<br />8 FACILITY NAME (tit not Institution, give street and num)
<br />CHI Health St, Francis
<br />8e:;clIYOR TOWN -OF DEATH (Include Zip Code)
<br />Grand =island' 88803
<br />Rlt44DENCE-
<br />Nebraska
<br />TI'T AiO:NUNR..
<br />0 E'> Su►ttset vldI lie
<br />Sb. COUNTY
<br />Hall
<br />6a. AGE - Last!8irthday
<br />(Yrs.)
<br />83
<br />5b: CN
<br />R 1 YEAR
<br />2. SEX
<br />Female
<br />6c. UNDER 1 DAY
<br />3. DATE OF DEA7
<br />21 17$G7
<br />pi tr,
<br />6. DATE QF STH.
<br />MOS.
<br />(iff PLACE
<br />HOSPilAt. :1 inpatient OTHER I❑ Nursing Honte&L1C
<br />❑'ER/Outpatient ❑ Decedent'stlpld. -
<br />DOA 0 Other (S
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 20, 1::.
<br />...STA AT TIME OF DEATH ® Married 0 Never Marled
<br />❑ Married, but seiperated O Widowed 0 Divorced ❑ Unknown
<br />1. FATHER'B.NAME {Pkat, Middle, Last, Suffix)
<br />harry Lars04'i
<br />13.1«yf:R N M ARMED:FORCEB? Give dates of service if Yes.
<br />. Nei NO, or Unk.) NO
<br />THOD OF DISPOSITION
<br />rattai 0 Donation
<br />9c. CITY OR TOWN
<br />Grand Island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />le. APT. NO.
<br />6f. ZIP CODE
<br />68801
<br />40b. NAME :OF SPOUSE (Fit, ' Middle, Last, Suffix) If wtfe, g)ve
<br />Carl Wayne Switzer
<br />12 MOTN&Rw$.NAME (PIM,Vfiola' Peterson
<br />14a. INFORMANT -NAME
<br />Carl Wayne Switzer
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />0remetion DI ntpli (matt 1tkl. CEMETERY, CREMATORY OR QTI!
<br />iiiriovat :' :❑ osis (specify)
<br />Grand Island Citv Cemetery
<br />LOCATION
<br />Ta. ryNERAt.. frota HAMILANDMAJtJNG ADDRESS (Street, City or Town, State)
<br />All Fai(hs Funeral F;iome, 2929 S. Locust Street. Grand Island. Nebraska
<br />16b. LICENSE NO.
<br />1397
<br />Middle, Mal
<br />CITY / TOWN
<br />Grand Island
<br />CAUSE OF DEATH • (See: instructions and examples)
<br />1a. PAR Il. Enter Meehsina �b- -dimmest, Injuries, or complcations4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional line k neseeeary.
<br />Sequentially lint conditions, if
<br />atq, (epd ng to tlt4 3403043M
<br />Atttl4e a .
<br />3i:the .rNosar 1'INC.GlkiiSE'"
<br />sirase>aiiy'iildtt EAd
<br />.vents resulting in death)
<br />LAST
<br />RTti.
<br />IMMEDIATE CAUSE:
<br />a) intracranial bleeding
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) hypertension
<br />DUE TO, OR A8 A CONSEQUENCE OF:
<br />0)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />vsgyt SiGNi i.GANT CONDITIONS -Conditions contributing to ttfe death
<br />regnant at#&na of dant t
<br />i'Eot Pregnd 01 but pr .hent within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 yaarbetore death
<br />Uidtrhown Kprepnantwphin the peat year
<br />AT i DP IROURY (tVlo ;Day, Yr.}
<br />22 . INJURY AT WORK?
<br />'S OYES DNQ
<br />CATIWN:QF ttNetee STREET & NUMBER, APT.NO. CITY/TOWN
<br />21a. MANNER OF DEATH
<br />® Natural El Homlatde
<br />0 Accident ❑ Pandlbg fn040g001
<br />0 Suicide ❑ Could not be determined
<br />not
<br />ultitg;n the undertytng cause given
<br />22b. TIME OF INJURY
<br />4M.
<br />PART 1.
<br />210IF TRANSPORTATION INJURY
<br />tj DrivedOperetor
<br />ri Passenger
<br />1 Pedestrian
<br />0 Other (Specify)
<br />22c. PLACE OF INJURY At horrie,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />23e. DATE OF'DEATH (Mo., Day, Yr.)
<br />December 16, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Pei:et:Aber 19, 2021 10:07 PM
<br />T4 bili b$9tof min nowlidgs, death occurred at the time, date and place
<br />acid due tit Ida G res(s) state, (Signature and Title)
<br />•
<br />The Wut Yee. MD
<br />2& Deli TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />D YES ❑ 140 PROBABLY ® UNKNOWN
<br />!d>&ME, rillt tNt A ESS OP CERTIFIER (Type or Print
<br />`)'tile Wut Yee MO
<br />; 2620 W Faidley Ave, Grand Island, Nebraska, 68803'
<br />rnh, s
<br />21c. WAS
<br />❑ YES.
<br />21d. WERE
<br />TO
<br />❑ YES 0..510
<br />reef, factory, office building,
<br />STATE.
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b,WS 0P'DEA'
<br />)24d. TIME D
<br />. t3n the basis of examination and/orinvestigation, in my Mktitah d
<br />fila Umei'date and place and due to the causes) *1518 , )$lgflatetS.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERD?
<br />0 YES bia NO
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT
<br />Not Applicable if 26e te NO
<br />28b. DATE FILED am I
<br />december 23, 2021
<br />
|