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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL pF THE NEBRASKA DEPARTMENT OF HEAGTH
<br />7HE BELOW TO BE A TRU�' COPY OF THE �RIGINAL RECORD ON FILE WITH THE NEBRASKA
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE �EGAL DEPOSITORY FOR 1/I�AL
<br />DATE OF ISSUANCE
<br />09/14/2009
<br />2012Q287�
<br />,N�/M�1� SERVICES, IT GERTIFIFS
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<br />LINCOLN, AIEBR.4SKA ti(�',M SER�/ICES _ ` R=, *�
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER17� ��•�q,��' -� �� ��- h� a y-O9 QZOO4�
<br />CERTIFICATE OF DEATH - .. f , �,g� ;< ••.�;�:k --° , r :` -� -
<br />7. DECEDENTS•NAME (Fhat, Middle, Last, Suffbt) 2. SEX F.`•. �1QATE;OFb�ATH�(Mo., Day, Yr.)
<br />Donald Hen Sm(th Male ` � `, . :Augugt�t; 2009 ' `
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Bhthday b. UNDER 1 YEAR bc. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />I�'�•) M09. DAYS HQURS MINS.
<br />ioux Falls, South Dakota 77 November 8, 1931
<br />7. SOCIAL SECURRY NUMBER 8a. PLACE OF DEATH
<br />504-20-2748 �❑ InpadeM OTHER ❑ Nuraln8 Home/1.TC � Hosplee FacflHy
<br />8b. FACILITY-NAME (ft irot I�tid�don, give atreet a� number) ❑ ERIOutpaUe� � Decedent's Home
<br />�
<br />� 309 W. Phoenix Ave ❑ DOA ❑ Other (Specify)
<br />n
<br />� 8c. �CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
<br />o �rand Island 68803 Hall
<br />� 8a. IDENCESTATE 9b. COUNTY 9c. CiTY OR TOWN
<br />w Nebraska Halt Grand Island
<br />LL 8d. Ef AND NUMBER 9e. APT. NO. 8t. ZIP CODE 88• �N$IDE CITY LIMITS
<br />309 W. Phoenix Ave 68803 ��s ❑ No
<br />� 1o�r MARITAL STATUSAT TIME OF DEATH � Martied ❑ Never IV�rried 10b. NAME OF SPOUSfi (Firat, Middle, Last, s►�rrnq rc wrca, gtve maiden name
<br />�, �;] �r�ed but separatad ❑ Wldowed ❑ DlvorceA ❑ unk�own Judy Gurgel
<br />� 11. �ATHER'S�NAME (Firet Middle, I.ast, Suftix) 12. MOTHER'S-NAME (Firet, Mlddie� Maiden Sumame)
<br />�lerome Smith Emma Mundt
<br />�' 73. �VER W U.9. ARMED FORCES? Gfva dat� of aervlee H YBB. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />5
<br />$ es, No, or unk.) Yes 10/05/1955-10/04/1957 JUdy Smlth Wife
<br />,$ 75. METHOD DF DISPQSITION 18a. EMBALMER-SIGNATURE 18lL LlCEN9E NO. 18c. DATE (Mo., Day, Yr.)
<br />� ��� ❑ °oi �� On Daniel D Naranjo 1071 August 27, 2009
<br />� Crematlon D EMombment, , �gd. CEMETERY, CFlEMATOR�f OR OTHER LOCATION CITY/ TOWN STATE
<br />� Removal ❑ Other (Spect(y)
<br />Grand Island Ciiy Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRE38 (Street, CHy cr7own, Sfate) 77b. Zip Code
<br />All Fafths Funeral Home, 2929 S. Lowst Street, Grand Island, Nebrdska 68801
<br />CAUSE OF DEATH See instructfons and exam les
<br />1& PART L Enoar Ure ehain otevems..diseases. tNur�sa, or comWicanone.u�ae a�remtr causea nre aeaa�. oo Nor aMar �em�nai eveMe euch as ceraua mrea�, : APPROXINUITE INTERVAL
<br />respiratory arreat, or veMricuiar fl6rillatlon wkhout el�owing the etlology. DO NOT ABBREVIATE. E�rter Only one ceuse on a pna. AEd addtdonat Ilrtes B neces8ary. � � .
<br />IMIN�b1ATE CAUSE ; onsat W death
<br />�nmeowTS cause � a) Natural Causes • : Immediate
<br />dtseaee or cwtdM4m reeultln8 � i
<br />� d �'� DUE TO, OR AS A CONSEQUENCE 9F: ' o�et to death
<br />s�ity u�c �am�, a b) Heart Attack � Immediate
<br />any. leatling ro the cauae Iiated � � . ; .
<br />� ,
<br />on yne a DUE TO, OR AS A CONSEQUENCE OF: � oriset W death
<br />ErHar pte UNDERLYINO CAUSE C )
<br />(disease w Wury that Inklatetl
<br />ttie'�evente resultlng In deatt�) DUE TO, OR AS R CONSEQUENCE OF: C onset to death
<br />LAST - . � � d � _ . . � .
<br />18. �ART p. OTHER SIGNIFlCANT CONDITIONS�Conditlo� conbibuting to the death but not resulUng in the umierlying cause gtven irt PART L 19. WAS MEDICAL EXAMINER
<br />Hi�h Blood Pressure And Congestive HeaR Failure OR CoRONER CoNTACTED?
<br />� ❑ YES � NO
<br />� 20. ��' FEMALE: 21a. MANNER OF DEATH 216. IF TRANSPORTATION INJUR 21a WAS AN AUTOPSY PERFORMED?
<br />F � �NOtpregn8ntwkhlnpaetyear - � Neturet � Hqmidde � DrivedOperstm �
<br />,�,� � ❑ res p No
<br />� L.. Preg^e^t ffi t�e °� deazh �. Aaide�rt �,� Pending Imestigetlon ❑ P�
<br />❑ Not pregnairt, but pie¢nairt wnhln 42 deys oi death Q aetlestrian Z1d. WERE AUTOPSY FlNDINOS AVAILABLE
<br />� � 9Wdde � coU�d rrot be determ��red TO COMPLETE CAUSE OF DEATH?
<br />� Not pre8�. but pregnant 43 daya to 1 year betore death �� Other (BPec�tY) �
<br />� ❑. Untmown R pregnarrt wH1Un the v� Yee� . . - . � � � � Q . YES _ ❑ NO
<br />� ZZa� DATE OF INJURY (Mo., Day, Yr.) ZZb. TIME OF INJURY 22c. PLACE OF INJURY•At homa, farm, atreet, fadory, ofllce bullding, aonshvctlon sfte, etc. (Specffy�
<br />$
<br />� 22d. INJURY AT WORK7 22e. DESCRIBE HOW INJURY OCCURRED
<br />H
<br />❑ YES ❑ NO
<br />92f. LOCATION OF INJURY • STREET B NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE BIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� .� �� September 1U, 2009 Approx. 03:00 AM
<br />� } 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ���� 24c. PRONOUNCED OEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E� �` �a 6 t � Au ust 24� �009 06:50 AM
<br />$ � . To the ba� 01 my knowleMBe. dasth occurted at Ure 6me� date and ptaee $.;t r z � 24e. On the basls of eraminatlon antl/or Imeatl9aHOn. In mY apWon deatA oeeurtetl et
<br />�� m�d due to tha cauae(s) alated (s�8��+ra mM TMIe) �� me mrre. dace mw a�ace ma aue m nre eaus�s).smma. (s�asure m�a rrnel
<br />~�, ~ o g Barbara Dunn; Hall Deputy County Attomey
<br />25. DID TOBACCO USE CONTRIBIiTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED7 26b. WAS CONSENT GRANTED?
<br />YES ❑ NO ❑ PROBABLY � UNIOV0IAIN ❑ YES � NO NotAppllcable H28a Is NO ❑ YES ❑ NO
<br />27. E, TIT E AND DRES9 F CERTIFI SI , SI I , CORONER S PHY I CO A R EY� (Type or Print)
<br />Barbara Dunn, Hall Deputy County Aftomey; 231 S: Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a, kiEQISTRAR'S SIGNATURE �` 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />September 14, 2009
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