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To be completed by: CERTIFIER To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Lilah Leona Smith 2. SEX. Female; 3, 4 O DEATH (Mo., Day, Yr.) December 22, 2011 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Hamilton County, Nebraska 5a. AGE - Last Birthday (Yrs.) 82 5b. UNDER 1 YEAR 5c. UNDER fo y.. 1. DATE OF'BIRTH (Mo., Day, Yr.) MOS. DAYS HOURS MIN Fe t ruary 26, 1929 7. SOCIAL SECURITY NUMBER 508 -30 -8094 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ® Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other(Specify) 8b. FACILITY -NAME (If not Institution, give street and number) Good Samaritan Society -Grand Island Village 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4079 Timberline St 9e. APT. NO. 103 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS Ei YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name James Wilbur Smith 11. FATHER'S -NAME (First, Middle, Last, Suffix) William Hahle 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Esther George 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or link.) No 14a. INFORMANT -NAME Steven Smith 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) December 29, 2011 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a, FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See and examples) 18. PART I. Enter the chain of events. -diseases, injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final al End Stage Vascular Dementia About 10 Years disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b)Chronic Cerebrovascular Disease More Than 20 Years any, leading to the cause listed on inc I a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or Injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART I. Arteriosclerotic Cardiovascular Disease 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 49 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident 0 Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE a W m z Y E 6 E i 23a. DATE OF DEATH (Mo., Day, Yr.) December 22, 2011 2, i i g.", p 1 N t 8 w G z 2 p ~ f..) s 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) December 23, 2011 23c. TIME OF DEATH 08:45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 a 0 9d. To the best of my knowledge, death occurred at the time, date and place 8 o and due to the c auses) stated. (Signature and Title) a Steven Husen. MD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, Steven Husen, MD, 2116 W Faidley #400, Box HYSICFAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A 9802, Grand Island, Nebraska, 68803 TORNEY) (Type or Print) r 28a. REGISTRAR'S SIGNATURE A- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 28, 2011 STATE OF NEBRASKA WHEN T COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BEL •rh TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN Simi' VICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ATE OF ISSUANCE 201407396 SN s "R A SIS'` ANT STATE,REGISTRAR DEPARTMENI«"OF HEALTH. AND INCOLN, NEBRASKA HWAN STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 12/30/2011 11 04308