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WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMN SERVICES
<br />SYSTm R Cmms THE BELOW-TO BE A TRUE COPY OF THE OR1G! V FXE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA: - VMICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS =
<br />` r
<br />DATE OF ISSUANCE
<br />5/9/2003 200307621 = R
<br />SrAf hI` R
<br />EAH LINCOLA NEBRASKA LT RI M &YSf EM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND S&$CS FIlA(�►I i@ SUPPORT
<br />VITAL STAT1SnCS - - _ 0 G 0 3 9
<br />CERTIFICATE OF DEATH- _ - =
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />;o
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Rita Marie Schwieger
<br />C)
<br />rn
<br />If
<br />4. CITY AND STATE OF BIRTH fNnot M U.S.A. name country)
<br />5a AGE -Last Birthday
<br />UNDER 1 YEAR
<br />' UNDER 1 DAY
<br />6. DATE OF BIRTH (Month. Day. Year)
<br />0
<br />C�
<br />n n z
<br />5c. HOURS MINS.
<br />Marna, Nebraska
<br />(pit
<br />_.
<br />�. `
<br />-
<br />o
<br />Be. PLACE OF DEATH
<br />ry
<br />O
<br />= D C7
<br />❑ ER Outpatient ❑ Residence
<br />Ob. FACILITY -Name #1 insmition, give smear and number)
<br />e St. Francis Skilled Care Nursing Unit
<br />❑ DOA ❑ Other fSpeciyi
<br />Sc. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes 2 No ❑
<br />Hall
<br />C
<br />C::)
<br />9b. COUNTY
<br />rn N
<br />9d. STREET AND NUMBER flnc /ud/rgZip Cade)
<br />ge. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />915 W. 8th 68801
<br />^.
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc)
<br />CD
<br />13. NAME OF SPOUSE tit wde. give maiden name)
<br />. etc.)(Speciq) White
<br />(Specify) Danish /Irish
<br />NEVER DIVORCED
<br />MARRIED Fl
<br />Melvin W. Schwieger
<br />I
<br />14a. USUAL OCCUPATION (Give kind of work dare during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary 10 -121 College I7 -a or 5.1
<br />of working life, even ifre6red)
<br />Registered Nurse
<br />Nursing
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Edward Sweeney
<br />Delia Kaelin -.
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />es. no. or unk) I (dyes. give war and dates of services)
<br />Jo
<br />Melvin Schwieger
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />915 W. 8th Grand Island, NE 68801
<br />20. EMBALMER - SIGNATURE & LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21
<br />c. CEMETERY OR CREMATORY - NAME
<br />Service
<br />Not Embalmed
<br />❑ Burial ❑ Removal
<br />=
<br />Central Nebraska Cremation
<br />22a. FUNERAL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Curran Funeral Chapel
<br />®°rithali 1 ❑ Ddnatl °n
<br />719 Front St. Gibbon, NE 68840
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />3005 South Locust St. Grand Island, NE 68801
<br />R;
<br />r
<br />DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />I
<br />TY
<br />DUE TO, OR AS A CONSEQUENCE OF:_ - I Interval between onset and death
<br />CD
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART III IF FEMALE. WAS THERE A 24.
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART d
<br />1,,41 e Ar
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />CC
<br />S� �u - (%
<br />(Ages 10-54) Yes No
<br />Yes No
<br />Yes No
<br />26e.
<br />28b. DATE OF INJURY (Ma: Dlsy. W..)
<br />M
<br />ti
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26f. PLAN eu10dIF,1INJURY
<br />dfifi 1NN U ���, farm. street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Vey ❑ No ❑
<br />M7
<br />CD
<br />27a. DATE OF DEATH (Mb.. Day. Yr.)
<br />N
<br />Od ©
<br />Cl6 !"
<br />w 4 . al
<br />7
<br />b-
<br />M
<br />3'
<br />27b. DATE SIGNED (Ma. Day Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day, Yr.)
<br />S
<br />("
<br />CD
<br />F_a
<br /><r
<br />M
<br />s'
<br />27d. 7o the beet of my k eMt a the time, and place and due to Me
<br />,_ 2Be. On the basis d examination and/or investigation, in my opinion death occurred at
<br />causelld stated.
<br />v a the time, date and place and due to the causels) stated
<br />IS nawre and Trial ►
<br />IS ature and Title
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ UNKNOWN
<br />❑ YES N NO
<br />❑ YES NO
<br />1
<br />z
<br />Q
<br />Lot Two (2) in Block
<br />Thirteen (13)
<br />in H.G.
<br />Clark's Addition
<br />to
<br />the
<br />City
<br />of Grand
<br />Island, Hall County,
<br />Nebraska
<br />WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMN SERVICES
<br />SYSTm R Cmms THE BELOW-TO BE A TRUE COPY OF THE OR1G! V FXE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA: - VMICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS =
<br />` r
<br />DATE OF ISSUANCE
<br />5/9/2003 200307621 = R
<br />SrAf hI` R
<br />EAH LINCOLA NEBRASKA LT RI M &YSf EM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND S&$CS FIlA(�►I i@ SUPPORT
<br />VITAL STAT1SnCS - - _ 0 G 0 3 9
<br />CERTIFICATE OF DEATH- _ - =
<br />1. DECEDENT - NAME FIRST MIDDLE LAST
<br />2. SEX I -
<br />3. DATE OF DEATH /Month. Day. Year)
<br />Rita Marie Schwieger
<br />Female
<br />May 4, 2003
<br />4. CITY AND STATE OF BIRTH fNnot M U.S.A. name country)
<br />5a AGE -Last Birthday
<br />UNDER 1 YEAR
<br />' UNDER 1 DAY
<br />6. DATE OF BIRTH (Month. Day. Year)
<br />(Yrs.)
<br />Sb. MOS. i DAYS
<br />5c. HOURS MINS.
<br />Marna, Nebraska
<br />74
<br />April 19, 1929
<br />7. SOCIAL SECURTIY NUMBER
<br />Be. PLACE OF DEATH
<br />507 -38 -5671
<br />HOSPITAL ❑ Inpatient OTHER: ® Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />Ob. FACILITY -Name #1 insmition, give smear and number)
<br />e St. Francis Skilled Care Nursing Unit
<br />❑ DOA ❑ Other fSpeciyi
<br />Sc. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes 2 No ❑
<br />Hall
<br />9a. RESIDENCE - STATE
<br />9b. COUNTY
<br />9c. CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER flnc /ud/rgZip Cade)
<br />ge. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Grand Island
<br />915 W. 8th 68801
<br />Yee K] No ❑
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY (e.g.. Italian, Mexican, German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE tit wde. give maiden name)
<br />. etc.)(Speciq) White
<br />(Specify) Danish /Irish
<br />NEVER DIVORCED
<br />MARRIED Fl
<br />Melvin W. Schwieger
<br />I
<br />14a. USUAL OCCUPATION (Give kind of work dare during most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION
<br />(Specify only highest grade completed)
<br />Elementary or Secondary 10 -121 College I7 -a or 5.1
<br />of working life, even ifre6red)
<br />Registered Nurse
<br />Nursing
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Edward Sweeney
<br />Delia Kaelin -.
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />es. no. or unk) I (dyes. give war and dates of services)
<br />Jo
<br />Melvin Schwieger
<br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />915 W. 8th Grand Island, NE 68801
<br />20. EMBALMER - SIGNATURE & LICENSE NO.
<br />21 a. METHOD OF DISPOSITION
<br />21b. DATE 21
<br />c. CEMETERY OR CREMATORY - NAME
<br />Service
<br />Not Embalmed
<br />❑ Burial ❑ Removal
<br />5 -4 -03
<br />Central Nebraska Cremation
<br />22a. FUNERAL HOME -NAME
<br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Curran Funeral Chapel
<br />®°rithali 1 ❑ Ddnatl °n
<br />719 Front St. Gibbon, NE 68840
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />3005 South Locust St. Grand Island, NE 68801
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). (b)- AND (c)) Interval between onset and death
<br />PART 1
<br />I I.I (�A4 N / Aw
<br />DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and death
<br />I
<br />�) I
<br />I
<br />DUE TO, OR AS A CONSEQUENCE OF:_ - I Interval between onset and death
<br />(cf I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART III IF FEMALE. WAS THERE A 24.
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART d
<br />1,,41 e Ar
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER?
<br />S� �u - (%
<br />(Ages 10-54) Yes No
<br />Yes No
<br />Yes No
<br />26e.
<br />28b. DATE OF INJURY (Ma: Dlsy. W..)
<br />260. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />26e. INJURY AT WORK
<br />26f. PLAN eu10dIF,1INJURY
<br />dfifi 1NN U ���, farm. street. factory
<br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
<br />Homicide Investigation
<br />Vey ❑ No ❑
<br />M7
<br />27a. DATE OF DEATH (Mb.. Day. Yr.)
<br />20a. DATE SIGNED (MO.. Day. Yr.)
<br />28b. TIME OF DEATH
<br />w 4 . al
<br />7
<br />b-
<br />M
<br />3'
<br />27b. DATE SIGNED (Ma. Day Yr.)
<br />27c. TIME OF DEATH
<br />28c. PRONOUNCED DEAD (MO.. Day, Yr.)
<br />28d. PRONOUNCED DEAD /Hour)
<br />r
<br />SI. V-03
<br />0455 M
<br /><r
<br />M
<br />s'
<br />27d. 7o the beet of my k eMt a the time, and place and due to Me
<br />,_ 2Be. On the basis d examination and/or investigation, in my opinion death occurred at
<br />causelld stated.
<br />v a the time, date and place and due to the causels) stated
<br />IS nawre and Trial ►
<br />IS ature and Title
<br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />30.b WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ UNKNOWN
<br />❑ YES N NO
<br />❑ YES NO
<br />31. NAME AND ADDRESS OF GERTIFItH (HHYSIGIAN, WHUNtHS 1'HYSIOWN Uri UUUNI T Al 1UHNtTI (rypearnrnl
<br />Dr. David R. Colan M.D. 729,N. Custer Av4 Grand Island, NE 68803
<br />32a. REGISTRAR /�j / "UAIt rILtU tsY Het;ISIHAH (mo..3'rrf
<br />� f( /Vr�y//II�! /j 1(W /n-tYT MAY -72003'
<br />7 Z00�
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