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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALT~~jI"-1~`ll%~N, SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRq,SKA~~EI2~lI~TF1t~PdT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FORV.~p4~.RE~'L~'RDS,, '
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<br />DATE OF ISSUANCE ~~f ~~ . w ~~ ,
<br />$.TAIV4EY CppP~'R .. a, '
<br />JAN 2 9 2010 2 010 0 0 8 3 3 A',S&ISTAlS~~T~'~.~~~ ,
<br />LINCOLN, NEBRASKA ~pt"~`TMENT QF hb~ATH RN~?
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN ~3ERVICI?S ~ ~ ~Q~ r~ ~ r
<br />CERTIFICATE OF DEATW ° ' o wi I ~ ~ ~ 0 '
<br /> 1. DECEDENTS-NAME (First Middle, Last Suffix) 2 SEX 8. DATE OF DEATH (Ma.,Day,Yr.)
<br /> Ohleen LaVonne Swanson Female March 15, zoos
<br /> 4. GITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Be. AGE-Last Birthday Bb. UNDER 1 YEAR Bc. UNDER 7 DAY 8. DATE OF BIRTH (Mo., Day, Yu)
<br /> (Yn,) Mp$. DAYS HOURS MINE.
<br /> Burwell, Nebraska 87 March 18, 1920
<br /> 7. SOCL4L SECURITY NUMBER Be. PLACE OF DEATH
<br /> 508-12-0559 HosPtTAL: ^ Inpaderd Q1HE(;;®Nunlnq Honte/LTC ^ Hwplce Feclllty
<br /> Bb. FACILIT•.'-NAME (If not Institution, glue slreel and number) ©ERIOutpsUent ^ Decadenri Home
<br /> - ^ DoA ^oda.r(an.enyi
<br /> Hamilton Manor
<br /> 8c. GITY OR TOWN OF bFATH (Includr Zip Code) 8d. COUNTY OF DEATH
<br /> Aurora 68818 Hamilton
<br />x ee. RESIDENCE-STATE t16. COUNTY ao. CrrY OR TOWN
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<br />Nebraska
<br />Hamilton
<br />Aurora
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<br />y tld. STREET ANp NUMBER 9a. APT. NO. 1K. ZIP CGDE 9g. INSIDE CITY LIMITS
<br />~ 1515 5th St. 68818 ®Yea ^ Na
<br /> toe. MARITAL STATUS AT TIME OF DEATH ^ Mewled ^ Newr Married 10b. NAME OF SPOUSE (Flnt Mddle, Lat SuRlx) H wlh, plw meldan name.
<br />~ ^ MBMad, but aparalad ®wldowed ^ Divorced ^ Unknown Forrest Swanson
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<br />a 11. FATHER'S-NAME (Pint, Middlr, Last, Sufrlx) 1t MOTKER'S-NAME (Pint Middle, Malden $umame)
<br /> Robert Ho es Edith Loretta Mattem
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<br />77. EVER iN U.B. ARMED FORCES? Olve dates of service ii Yes.
<br />14a. INFORMANT-NAME 11b. RELATIONSHIP TO DECEDENT
<br />~ (Ya, No, or Unk.) (ajp COnme SWaniion DaU hter
<br /> 78, METHOD OF DISPOSITION i6e. EMBALM IGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br /> ®°1M1' ^°oi'"'°" U.j t~ .~ ~4~ 9 7 March 19, 2008
<br /> ^CrwnRitln ^ErdOrntN1MM
<br /> ^Ramoval ^Othadewcey)
<br />CEME ERY, CREMATORY OR OTHER LOCATION CITY/7DWN STATE
<br /> Westlawn Memorial Park Cemetery Grand Island Nebraska
<br /> 17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street City or Town, Stale) 776. Zip Cade
<br /> All Faiths Funeral Hame, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH See Instructions and exam les
<br /> 7e. PARY I. Enter tn. S~alaadiC9a1S - dlawta, Inludaa, or campaeetiana-iMt direcay woad tM loth. DO NOT sour grmin4l .vnde aucn a eerelec enru, APPROXIMATE INTERVAL
<br /> napinnry una4 w wnirlCUlllr Ildrllleaon wlrhaur eaawida the Nlaltlay. as NOT AaBREVIA7E. FJltar arty o1N CeuN en a Nr,e. Add WdWonY IInN it rllesaeary.
<br /> IMMEDIATE GAUGE: i onaN to death
<br />IMMEDIATE CAUSE (Final
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<br /> dlsaaee orcandlUan resulting a) •
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<br /> In death)
<br /> ansN to dash
<br />DUE 70, OR AS A
<br />CONSE UCNCE
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<br />any, lead np to lhr cause I st
<br /> on Ilns a. DUE TO, OR AS A CONSEQUENCE OF: 1 ttmN to death
<br /> Enter the UNDERLYING CAUSE cl I
<br /> (dleaase or Injury that IMdated
<br />the evante rowldnq In death) DUE TO, OR AS A CONSEQUENCE OF; I onat to dufh
<br /> LAST
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<br /> 7B. PART IL OTHER SIGNIFICANT CONDITIONS-0ondidone contrlbutlnp to fhs death but net rnulUnp in tlw undadying taus given in PART I. 18. WAS MEDICAL F-XAMINER
<br /> OR CORONERCONTACTED7
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<br />^ YE8 NO
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<br />~ 20. IF FEMALE: 21a. MANNER OF DEATH 276. IF TRANSPORTATION IN.IURY 21c. WAS AN AUTOPSY PERFORMEb7
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<br />~ Not progn8nt within pat year
<br />~atunl ^ Homicide
<br />^ DrivaAOperator
<br />^ YES 0
<br />W Pregnant at Ums of death ^ Accident ^ Pandlnp Imesdpegan ^ Perrrngrr 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />U ^ Not pngnant but pregnant within 42 Jaya of death ^ Sulclde ^ Could not 6r drhmdrwd ^ PadatHan TO COMPLETE CAUSE OF DEATH?
<br />~' ^ Nvt pregnant but pregnant 4, days to 1 year bsfaro death ^ Other (SpacltY) ^ YES ^ NO
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<br />S ^Unknown if pregnant within the past year
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<br />~ 22a. DATE OF INJURY (Ma., Day, YrJ 224. TIME OF INJURY 22c. PLACE OF INJURYw4t home, farm, sheet factory, ofRce 6ulldlnp, conetructlan alu, etc. (Speclry)
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<br />22d. INJURY.47 WORK?
<br />22a, DESCRIBE HOW INJURY OCCURRED
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<br />^ YES Q NO
<br /> 22f. LOCATION OF INJURY -STREET IF NUMaER, APT. NO. CITY/TOWN STATE ZIP COpE
<br /> 29a. DATE OF DEATH Ma., Day, Yr.)
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<br />' aAe. DATE SIGNED (Mo., Day, Yr.) 246. TIME OF DEATH
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<br />~ 2Sb. DAT SIGNED o„ pay, Yr.) 27c. TIME OF OEATH ~ ~ Q 24c. PRONOUNCED DEAD (Mo., Day, Yr.) lad. TIME PRONOUNCED DEAD
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<br /> 'v ~ 27d. To fh a y knowledge, d th occurred the pme, date and place
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<br />Tid ~` W ~ t? 24s. On the bale o(sxenrlnstlon mdlor imertlpadon, in my opinion death occurred
<br />newn end Titlr)
<br />lace and due to the cause(s) ahMd
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<br />red the es s) stated 8 nature ^
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<br /> 28. DI TO CC US CONTRIBUTE TO THE DEATH? 28a. GAN OR TISSUE bONAT10N BEEN CONSIDERED? 786. WA8 CONSENT GRANTED?
<br />_ F~ ^ NO ^ PROBABLY ^ UNKNOWN ^ YES NO Not Applicable M lea la NO ^ YES ^ NO
<br /> 27. NAME, 71TLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICAN OR COUNTY ATTORNEY) (Typo or PMM)
<br /> Jeff Mua.lenbur M.D. 609 o t. Aurora NE 68818
<br /> 28a REGISTRAR'S SIGNATURE j
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<br />~^ 2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
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<br />~~ MAR 2 ~ ZO
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