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<br />y�� NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OP NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OP 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 OP ISSUANCE
<br />4f3t2023
<br />.INCOLN, NEBRASKA
<br />f
<br />m
<br />3VARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />IDE.DENT"$ NAME (First, Middle, Last, Suffix)
<br />Ftanald Eugene Schwab
<br />CERTIFICATE OF, DEATH
<br />4. oily AND STATE OR OR FOREIGN COUNTRY OF BIRTH
<br />Junction City, Kansas
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />63
<br />Sb UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />23 04108
<br />3. DATE OF DEATH (Ma, flay Yr)
<br />March 21,023
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />T BOCIA€.SECURITYNUMBER
<br />5O5-$2.7356
<br />Sb. FACILITY -NAME (II not Institution, give street and number)
<br />CHI Health St. Francis
<br />Sc. :CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d.: STREET AND NUMBER
<br />2318 Stardust Lane.
<br />8a. PLACE OF DEATH b
<br />HOSPITAL I Hnpattent
<br />d ER/Outpatlent
<br />❑ DOA
<br />9b. COUNTY
<br />Hall
<br />ITAL STATUS AT; TIME OF DEATH ® Married 0 Never Married
<br />Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S4IAME (Fust, Middle, Last, Suffix)
<br />riAerNiVi Eugene Schwab
<br />13:.'VER IN OS.ARMED FORCES? Give dates of service H Yes.
<br />(Yes,No, or Unk.) ND '
<br />16. METHOD QF DISPOSITION
<br /><Butfal 0 Dona#Ion
<br />Cremation Q Entombment
<br />❑Removal DOther(Spedry)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />October 22, 1959
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />Q Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />tie. APT. NO.
<br />9f. ZIP CODE
<br />68803ail
<br />Q Hospice Facility
<br />90. INSIDE CITY LIMITS
<br />YES ❑ rNO..„
<br />14b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Susan Busch
<br />14a. INFORMANT -NAME
<br />Susan Schwab
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />12, MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Mary Margaret Keehn
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />St. Mary's Cemetery
<br />179,FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Rasmussen Mortuay.311 Grand Avenue, Ravenna, Nebraska.
<br />16b. LICENSE NO.
<br />1191
<br />CITY / TOWN
<br />Pleasanton
<br />14b. RELATIONSHIP TO DEcEDEN r::
<br />Wife
<br />16c. DATE (N54, Day,:;Yr.)
<br />March 25, 2023
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of events- -diseases, injuries, or compllcatlonsNwt 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 lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Cardiogenic shock
<br />lAtIS8 lPina.
<br />dh8q#e or cdndidon reediting
<br />STATE
<br />Nebraska
<br />17b. 2t(C Code:
<br />588813: '+
<br />APPROXIMATE INTERVAL
<br />onset mu
<br />1. Day
<br />in deWS .:.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) heart failure
<br />Sequentially list conditions, if
<br />uty, toadied to the.neuse Usted.
<br />on:iip9 a
<br />Eider;tile UNDEI%Y(NO
<br />(dis cOf I(1jut hat inigated
<br />the events resulting in death)
<br />LAST
<br />onset to death
<br />5 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18-i!ART IL.OTHER SiGrOFICANT CONDITIONS -Conditions contributing to the death but not :resulting:in the underlying cause given In PART I.
<br />Severe aorticstenpsi$,.chronic systolic heart fallure,persistent atrial fibrillation,poor'compliance With medications and follow up
<br />20 IFFEMALE;
<br />. Q. Not pre9neel wxMn peat year
<br />E Pregnmd nt liph, Pf;:i1Pahfir
<br />❑ Not ptegnent but pregnant within 42. days of death
<br />❑ Not pregnent,::but pregnart43 days toil. year before death
<br />Q Unknown a gregnerd within the past year
<br />22a.;DATE OF INJURY (Mo. Day, Yr.)
<br />22d.INJURY AT WORK?
<br />❑YES Li NO
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homklde
<br />❑ Accident ❑ Pending Invenegation
<br />0 Buie de ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />214, IF TRANSPORTATION INJURY
<br />DOM/Operator
<br />0 Passenger
<br />Pedestrian
<br />0 Other (Specify)
<br />onset to death
<br />19.11IAS MED)OALEXAMINER.
<br />OR CORONER CONTACTED?
<br />I YES ❑ No
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE'
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, :farm street, factory, office building, construction site, etc. (Speak)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />TION OF IfdJURY-STREET & NUMBER, Ap'r.NO.
<br />23e. DATE OF DEATH (Mo., Day, Yr.)
<br />March 21 2023
<br />CITY/YOWN:'
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Mi rct} $3.:.2023 12;42 PM
<br />22d, To the beat of my knowledge, death occurred at the time, date and place
<br />and due to the.C*uea(s) stated. (Signature and Title)
<br />Srikanth Reddy Kothapalli, MD
<br />26 DID TOBACCO USE CO B
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2IP CODE.
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED: DEAD::::...
<br />24a. On the basis of examination andior Investigation, In my opinion death etmuired et
<br />the time 'date and place and due to the causes) stated. (Signature stili T1tie)
<br />NTRI UTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE. DONATION BEEN CONSIDERED?
<br />❑,`YE$ NO PROBABLY ®UNKNOWN
<br />DYES I NO
<br />27 NAME, 0TLE NO ADDRESS OF CERTIFIER (Type or Print
<br />Srikanth ReddyKothapalii, MD, 2620 W Faidley Ave, Grandisland, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO D YES '; 0
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 29, 2023
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