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WHEN fW COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALW,4WAU9WMWCES SYSTEM IT CERTIFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORBF ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS �Sp THE LEGAL DEPOSITORY FOR VITAL RECORDS., DATEOF/SSUANCE Pinewood Condominium of Lts DEC 14 2000 28 to 38, Brentwood 3rd Sub: �.R Suite 4 2808, Grand Is1 ASSLSFTANfSti1 rREGISTRAR LINCOLN, NEBRASKA Hall County, Nebrask*A14hANDHOMANSERVICE$SYS.TEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUKAN SERVW, -ES FOIANCE AND SUPPORT 200107846 VIAL STATISTICS rRAT T7TrATP CIP nPATV4 1. 1 DECEDENT - NAME FIRST MIDDLE '. A$' — -- PART ,I� IF FEMALE WAS THERE A T PAST 3 MONTHSp m ! n n Female December 4, 2000 M �o UNDER 1 YEAR T' C- j t M N ScHMarch c� cn o "{ p C.0 jj (Jo S> III �`_ f 506 -20 -5234 _ HOSPITAL Z N -s C 1 I ~ �� ER Outpatient ❑BD ❑ DOA ❑ Residence ❑ Other Soemri _- FACILITY -Name /l/nnt institution, give street and numbeQ Tiffany Square Care Center 271 DATE OF DEATH /Mo.. Day YO C::) 80. CITY TOWN OR LOCATION OF DEATH $ o-, 27b DATE SIGNED IMO. Day. Yrl 27c TIME OF DEA __ }}rr Be COUNTY OF DEATH M - -- ( � �] Q CD C/7 J iS, nature and Title) ► -.- (Si nature and Tithe) ► WAS CONSENT GRANTED' 29 DID TOBACCO USE CONTRIBUTE TO THE DE T 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED1 __T 121 �ES ❑ ❑ ❑ YES NO ❑ YES IO NO UNKNOW -- 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, 'r✓pe or Print,, Gordon J. Hrnic k M.D. 729 North Custer, u' 32a. REGISTRAR 32b DATbff REGISTRAR_ 00o y Yi cm © CD .. .. ` G 1 WHEN fW COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALW,4WAU9WMWCES SYSTEM IT CERTIFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORBF ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS �Sp THE LEGAL DEPOSITORY FOR VITAL RECORDS., DATEOF/SSUANCE Pinewood Condominium of Lts DEC 14 2000 28 to 38, Brentwood 3rd Sub: �.R Suite 4 2808, Grand Is1 ASSLSFTANfSti1 rREGISTRAR LINCOLN, NEBRASKA Hall County, Nebrask*A14hANDHOMANSERVICE$SYS.TEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUKAN SERVW, -ES FOIANCE AND SUPPORT 200107846 VIAL STATISTICS rRAT T7TrATP CIP nPATV4 1. 1 DECEDENT - NAME FIRST MIDDLE '. A$' — -- PART ,I� IF FEMALE WAS THERE A T PAST 3 MONTHSp 2 SEx -- 3 DATE OF DEATH r0.hv-ry Dim 11111 Wanda Mae Swanson Female December 4, 2000 4 CITY AND STATE OF BIRTH !lf not in USA.. name country) 5a. AGE - Last Birthday UNDER 1 YEAR U�111YNS 6. DATE OF BIR1 H ;Month. Dav Ye1r/ 5n MOS DAYS ScHMarch ' Grand Island, Nebraska (Yrs i 75 _ 9 , 1925 7 SOCIAL SECURITY NUMBER Ba LACE OF DEATH ❑ Inpatient OTHER a 11.1-111.1-11o, ur 506 -20 -5234 street factory HOSPITAL �� STATE -- yes ❑ No ❑ ER Outpatient ❑BD ❑ DOA ❑ Residence ❑ Other Soemri _- FACILITY -Name /l/nnt institution, give street and numbeQ Tiffany Square Care Center 271 DATE OF DEATH /Mo.. Day YO 28a DATE SI ED IMO. Day Yrl 28b TIME O H RECEIVED 80. CITY TOWN OR LOCATION OF DEATH $ o-, 27b DATE SIGNED IMO. Day. Yrl 27c TIME OF DEA __ Bd INSIDE CITY LIMITS Be COUNTY OF DEATH M - -- S p - ° in my opinion death oCCU(rBtl at Yes ® No ❑ Hall causefs) stated. Grand Island iS, nature and Title) ► -.- (Si nature and Tithe) ► WAS CONSENT GRANTED' 29 DID TOBACCO USE CONTRIBUTE TO THE DE T 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED1 __T 121 �ES ❑ ❑ ❑ YES NO ❑ YES IO I f ■ n Nebraska Hall 10 RACE - (e.g.. While. Black. American Indian. 11. ANCEST etc .I(Specify) Wtlite (Spec,fyl 14a USUAL OCCUPATION lGtve kind of work done during most of working life, even if retired) Homemaker 16. FATHER- NAME FIRST MIC Grand Island ieg Italian. Mexican. German. elcl 12. © MARRIE American NEVER ❑ MARRIE 14b KIND OF BUSINESS INDUSTRY Domestic I AST l' MOTHER d. STREET AND NUMBER llncluding Zip Cnde� 9e MSIDE DITY t,M,TS 3119 West Faidlev_ 68803 Yes N L� ❑ WIDOWED 13 NAME OF SPOUSE ;u wile give maiden name/ DIVORCED I Milton Swanson 15- EDUCATION Spec,ty, only n,ghesi grade completed) - �. Elementary or_Secondary IO -121 College 11 a o1 - - Lee Dewhirst 18 WAS DECEASED EVER IN U.S. ARMED FORCES' 19a INFORMANT NAME (Yes no or unk.) I (Ii yes give war and dates of services) No (Milton Swanson 19b INFORMANT MAILING ADDRESS !STREET OR R D NO CITY OR TOWN STATE ZIP, 2808 Brentwood Circle, Grand Island, Nebraska 68803 20 EMBALMER - SIGNATURE 8 LICENSE NO 21a METHOD OF OISPOS:T'C', 21b DATE NOT EMBALMED ❑ Burial ❑ Remlvai !- Dec . 5, 22a FUNERAL HOME -NAME 211 CEMETERY np{ a Ct, i l er Gedd �. L1 wver -.l L.1i-,. e a Cr lri ❑ Donal o, 22b. FUNERAL HOME ADDRESS 7 (STREET LOCRIRL.F.IDANIOI CCITY OR TOWN. STATE. ZIP( 1123 West Second, Grand Island, Nebraska 68801 FIRST MIDDLE mHiUery Clara Brown 21C CEMETERY OR CREMAT;)PI NAME 2000 I Central Nebraska CYmHtien Ser_ vioE CREMATORY LOCATION CITY jR TOWN STATE Gibbon, Nebraska 23 IMMEDIATE PNSE _ (ENTER ONLY ONE CAUSE PER LINE FOR �aI AND (c)1 _ PART (a) -- „-- -r DUE TO, OR AS A CONSEQU E OF i @I - DUE TO. OR AS A CONSEQUENCE OF- between onset ��r 1 `= rm_ I between onset anr, n. ar Interval between oneel ml, OTHER SIGNIFICANT CONDITION -S - DonA,LOnS centr,Durind rn the tlea:h but not role -ed — -- PART ,I� IF FEMALE WAS THERE A T PAST 3 MONTHSp -.— AUTOPSY —_ - -_ 25 WAS CA ;F REFERRED 7C) MEDICAL. EXAMINER OR CORONER -' PART PREGNANCY IN THE (Ages 10541 Yes No Yes No Yes No 26a 26b. DATE OF INJURY fMO.. Day. Yrl 26c HOUR OF INJURY 2161 DESCRIBE HOW INJURY OCCURRED Accident � Undetermined M Suicide ❑ Pen 26e. INJURY AT WORK 26f. INJURY -farm street factory 26g. LOCATI �� STATE Homicide Investigation yes ❑ No ❑ o8icebuOF lSpeafyj 271 DATE OF DEATH /Mo.. Day YO 28a DATE SI ED IMO. Day Yrl 28b TIME O H RECEIVED M $ o-, 27b DATE SIGNED IMO. Day. Yrl 27c TIME OF DEA __ > ° r 28c PRONG N D DEAD Hour' o - .r_ zi.aoN� g M M - -- S p - ° in my opinion death oCCU(rBtl at o & 27d. To the st of my nowle e. death occurred t time, late and pl3Ce and due to the ¢chi 281. On the eat Of d place examination and to the causepn. the time. dale and place antl due to the causes staled causefs) stated. _ , iS, nature and Title) ► -.- (Si nature and Tithe) ► WAS CONSENT GRANTED' 29 DID TOBACCO USE CONTRIBUTE TO THE DE T 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED1 __T 121 �ES ❑ ❑ ❑ YES NO ❑ YES IO NO UNKNOW -- 31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER S PHYSICIAN OR COUNTY ATTORNEY, 'r✓pe or Print,, Gordon J. Hrnic k M.D. 729 North Custer, Grand -- 32a. REGISTRAR 32b DATbff REGISTRAR_ 00o y Yi U ”