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- ~ STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. •,,
<br />Y.
<br />DATE OF ISSUANCE ~ -
<br />~EG1 ~ ~ ~~08 T/I11u.~Y•3,.•G`1~OP.,ER
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<br />LINCOLN, NEBRASKA 2 O O 9 O 5 4 U O HEALTH-~4ND~/uNA~I $ER~IGE3'
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<br />STATE OFNEBRASKA--pEPARTMENTOF HEALTH AND HUMAN SERVICES FINANCE~AND SUPP`OR3 '
<br />!t"_CL]TIFIP`ATC AC 1'1CATW .. F"1 © p ~'1 ~"1 ('1 r
<br />
<br />1. DECEDENT'S-NAME (First, Middle, last, Sufflx) 2.5EX 3.DA~EOFDEA7H (Mo.,Dey,Yr.)
<br />Lester NMN Schweitzer Male 'February 20, 2008
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. PATE OF BIRTH (Mo., Day, Yr)
<br />Wood River, Nebraska (vra.) gl MDS. Davs HouRS MINE. May 18, 1926
<br />7. SOCIAL SECURITY NUMBER 8e. PLACE OF DEATH
<br />506--28-0044 ~y,
<br />HOSPITAL: Q In
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<br />~$ 41 Nursing HomelLTC ^ Hospice Facility
<br />86.,FACILITY-NAME (li' not Inetltutipn, glue sirart-eRb nutnder) - - -- ~ ~ ~ ~ ~~~
<br />^ ER/Outpatient ^ Decedent's Home
<br />St. Francis Skilled Care Center
<br />C] txn ^ aher(specity)
<br />Bc. CITY OR TDWN OF DEATH (Include Zip Code) Bd. COUNTY OF pEATH
<br />Grand Island 68$03 Hall
<br />8a. RESIDENCE-STATE 86. CQUNTY 9c. CITY OR TOWN
<br />Nebraska Ha1,1 Cairo
<br />9d. STgEETANDNUMBER 9e. qpT. ND Bf. ZIP CODE 8g. INSIDE CITY LIMITS
<br />404 Berber St.
<br />68824 Xl YES ^ ND
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<br />10e. MARITAL STATUS AT TIME
<br />OF DEATH ^ Married ^ Never Married 106. NAME OF SPOUSE (First, Middle, Last, Sulllx) II wife, give maiden neme.^
<br />^ Merrled, but separated C~[Wldowed ^ bivorced ^ Unknown
<br />11. FATWER'S-NAME (First, Mlddle, Last, Sufflx) 12. MOTHER'S•NAME (First, Middle, Malden Surname)
<br />John H. Schweitzer Matilda Stutzman
<br />13. EVER IN U.3. ARMED FORCE57 give dates of service if yes. 14e. INFORMANT-NAME 146. RELATIONSHIP TO DECEDENT
<br />(Yes, no, orunk.) Na Sharon Jarzynka Daughter
<br />15. METHOD OF DISPOSITION 16a.EMBAL R- GNAT 18b. LICENSE NO. 18c. DATE (Mc., Day, Yr. )
<br />~Burlal ^ponaucn /.Z 5/Q February 23, 2008
<br />^Cremation ^Entombmflnt 18d.CE ETERY,CREM YOROTHERLOCATION CITYlTOWN STATE
<br />^Removal ^Other(Specify) Wood River Mennonite Cemetery Wood River, Nebraska
<br />17a. FUNERAL HOME NAME AND MAILINp ADDRESS (51r6et, City orTawn, State) 176. Zlp Cade
<br />Apfel Funeral Home, 1123 West Second, Grand Island, Nebraska. 68.$01 ...__
<br />18. PART I. Enter the Chain of evflnts-•diseases, In)urlbs, or compllcatlons--that directly caused the death. DO NOT enter terminal events ouch as Cardiac arrest, APPROXIMATE INTERVAL
<br />I
<br />respiratory arrest, or ventricular fibrillation without Showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. I
<br />IMMEDIATECAU5Er,..., I onset todeeth
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<br />dlaaaeeorcondidonnraulting DUE T0, OR A3 A CONSEQUENCE OF:
<br />I onset to death
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<br />Sequamlally Ilat conditions, II rol I
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<br />any,leedingtothecauaelieted pUETO,ORASaCON5E0UENCEOF: I onset to death
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<br />IA$F I On90t l0 death
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<br />18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PAR71. 78. WA5 MEDICAL EXAMINER
<br />OR CORONER CDNTACTE07
<br />^ YES ^ NO
<br />20. IF FEMALE: 21 .M ER OF DEATH 21b.IFTRAN5POR7ATI0NINJURY a1c.WASANAUTOPSYPERFORMED7
<br />^ Not pregnant within peat year Natural ^ Homicide ^ Driver/Operator ,y`
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<br />YES BLAND
<br />^Passen er
<br />^ Pregnant at time of death ^ Accident[] pending Investigation 8
<br />^ Not pregnant, but pregnant within 42 days of death ^ Pedestrian 21d. WERE AUTOPSY FINDINp3 AVAILABLE TO
<br />^ Suicide ^ Could not be determined
<br />^NOtpragnant,butpregnant43daystolyeerbeforedeath ^Other(Specify) COMPLETECAU5EOFDEATH7
<br />.. ~ D~Gn ,1M4.11_p~pngnlyv!thln lha peflt-yeaL...... .~- .. --. -. --..- ~- -....~...._ - - - -. - --.. ..
<br />_.. ~Y~S_ _- ~ NO --
<br />22a. PATE DF INJURY (Mo., pay, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY•At home, term, Street, factory, ofllce buildlnp, conelructlon site, etc. (Specify)
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<br />22d.INJURYATWORK? 22e.pE5CR18EHOWINJURY000URRED
<br />^ YES [] NO
<br />22f. LOCATION OF INJURY • STREET & NUMBEq, APT. N0. CITYROWN S'IA7E ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) ~ z 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF pEATH
<br />y s 23b. DATE SIGNED (Mo., Day, Yr.)LL 23c.TIME OF DEATH ~ ~ 24c. PRONOUNCED DEAp (Mo., Day, Yr.) 24d. TIME PRONOUNCED pEAD
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<br />23d. T the best of my knowledge, death occurred et the time, date end place w ~ 24e. On the basis ci examinatlonand/or investigation, In my opinion death occurred at
<br />e dYkt to ihe(s) rated. (Signature and Title) • ~ ~ p the time
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<br />25. DIDTOBACCQ USE CONTRIBUTETOTHE DEATH? 28a. HA5 pRGAN OR TISSUE DONATION BEEN CONSIPEREp7 266. WAS CONSENT GRANTED?
<br />^ YES NO ^ PROBABLY ^ UNKNOWN ^YES 0 Not Applicable if 28e Is Np ^YES ^ NO
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<br />. 27. NAME,TITEANDAbDRESSpFCERTIFIER (PHYSICIAN,CORONER'SPHYSICIANOR000NTYA ORNEY) (TypeaPrlni)
<br />Donald Wirth M.D. 2116 West Faidley Ave., Grand Island, NE 68803
<br />2Ba. REGISTRAR'S SIGNATURE 28b. PATE FILED BY ~F,61~R~ ~0., D~>~~y
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