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To be completed /verified by: FUNERAL DIRECTOR <br />1 <br />1. DECEDENT'S-NAME (First, Middle, Last, Suffix) <br />Carol Ann Smith <br />2. SEX : <br />Female <br />3. DATE OF. DEATH (Mo., Day, Yr.) <br />August 13, 2014 <br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH <br />Roseland, Nebraska <br />5a. AGE - Last Birthday <br />(Yrs.) <br />79 <br />fib. UNDER 1 YEAR <br />5c. UNDER 1 DAY <br />6. DATE OF BIRTH (Mo., Day, Yr.) <br />November 20, 1934 <br />MOS. <br />DAYS <br />HOURS <br />MINS. <br />7. SOCIAL SECURITY NUMBER <br />506-40 -2224 <br />8b. FACILITY -NAME (If not Institution, give street and number) <br />Edgewood Vista Grand island <br />8a. PLACE OF DEATH <br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility <br />❑ ER/Outpatient ❑ Decedent's Home <br />❑ DOA ® Other (Spec'fy SSISTED LIVING <br />8c. CITY OR TOWN OF DEATH (Include Zip Code) <br />Grand Island 68803 <br />8d. COUNTY OF DEATH <br />Hall <br />9a. RESIDENCE -STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY OR TOWN <br />Grand Island <br />9d. STREET AND NUMBER <br />214 N Piper <br />9e. APT. NO. <br />9f. ZIP CODE <br />68803 <br />9g. INSIDE CITY LIMITS <br />® YES ❑ NO <br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married <br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown <br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name <br />Gary Smith <br />11. FATHER'S -NAME (First, Middle, Last, Suffix) <br />George Loskill <br />12. MOTHER'S -NAME (First, Middle, Maiden Surname) <br />I Eva Hemberger <br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. <br />(Yes, No, or Unk.) No <br />14a. INFORMANT -NAME <br />Gary Smith <br />14b. RELATIONSHIP TO DECEDENT <br />Spouse <br />15. METHOD OF DISPOSITION <br />® Burial ❑ Donation <br />❑ Cremation 0 Entombment <br />❑ Removal ❑ Other (Specify) <br />16a. EMBALMER - SIGNATURE <br />Kevin Wood <br />16b. LICENSE NO. <br />1325 <br />16c. DATE (Mo., Day, Yr.) <br />August 25, 2014 <br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE <br />Westlawn Memorial Park Cemetery Grand Island Nebraska <br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) <br />Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska <br />17b. Zip Code <br />68803 <br />CAUSE OF DEATH (See instructions and examples) <br />To be completed by: CERTIFIER <br />18. PART I. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter tenninal events such as cardiac arrest, <br />APPROXIMATE INTERVAL <br />onset to death <br />Years <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. <br />IMMEDIATE CAUSE: <br />IMMEDIATE CAUSE (Final a) Progressive Dementia <br />disease or condition resulting <br />in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death <br />Sequentially list conditions, if b) I <br />any, leading to the cause listed I <br />on line a. <br />DUE TO, OR AS A CONSEQUENCE OF: : onset to death <br />Enter the UNDERLYING CAUSE c) I <br />(disease or injury that initiated ; <br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death <br />LAST d) I <br />t <br />1 <br />18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the d " but not resulting in the underlying cause given in PART I. <br />Osteoarthritis <br />19. WAS MEDICAL EXAMINER <br />OR CORONER CONTACTED? <br />® YES ❑ NO <br />20. IF FEMALE: <br />❑ Not pregnant within past year <br />0 Pregnant at time of death <br />❑ Not pregnant, but pregnant within 42 days of death <br />❑ Not pregnant, but pregnant 49 days to 1 year before death <br />❑ Unknown if pregnant within the past year <br />21a. MANNER OF DEATH <br />® Natural ❑ Homicide <br />❑ Accident ❑ Pending Investigation <br />❑ suicide ❑ Could not be determined <br />21b. IF TRANSPORTATION INJURY <br />❑ Driver /Operator <br />0 Passenger <br />❑ Pedestrian <br />❑ Other (Specify) <br />21c. WAS AN AUTOPSY PERFORMED? <br />❑ YES 0 N <br />21d. WERE AUTOPSY FINDINGS AVAILABLE <br />TO COMPLETE CAUSE OF DEATH? <br />❑ YES ❑ NO <br />construction site, etc. (Specify) <br />22a. DATE OF INJURY (Mo., Day, Yr.) <br />22b. TIME OF INJURY <br />22c. PLACE OF INJURY -At home, <br />farm, street, factory, office building, <br />22d. INJURY AT WORK? <br />❑ YES ❑ NO <br />22e, DESCRIBE HOW INJURY OCCURRED <br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE <br />. 6, <br />1 <br />1 2 <br />23a. DATE OF DEATH (Mo., Day, Yr.) <br />August 13, 2014 <br />To be completed by <br />CORONERS PHYSICIAN <br />or COUNTY ATTORNEY <br />ONLY <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24b. TIME OF DEATH <br />23b. DATE SIGNED (Mo., Day, Yr.) <br />August 25, 2014 <br />23c. TIME OF DEATH <br />11:13 AM <br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) <br />24d. TIME PRONOUNCED DEAD <br />11 u 0 23d. To the best of my knowledge, death occurred at the time, date and place <br />e . due to the cause(s) stated. (Signature nd Title) <br />2 Jane A. McDonald, MD <br />24e. On the basis of examination and /or investigation, in my opinion death occurred at <br />the time, date and place and due to the cause(s) stated. (Signature and Title) <br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />0 YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO <br />26b. WAS CONSENT GRANTED? <br />Not Applicable if 26a is NO ❑ YES ❑ NO <br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print <br />Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 <br />1 28a. REGISTRAR'S SIGNATURE ja - iO�J <br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) <br />August 25, 2014 <br />DATE OF ISSUANCE <br />01/28/2016 <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND,Nt. AN SERVICES, IT CERTIFIES <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NCBRA,Kat bf ft T 1h T,OF HEALTH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FORVIT44.hE <br />• STANLEY S, COOPER <br />,ASSISTA('AAT AF '¥EGISTkA <br />DEPAR�TIWN0,�` 41 TH :46lb ";, <br />HUMAN SERVICES • <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEliViCES /,' ., <br />CERTIFICATE OF DEATH E: <br />201601001 <br />14 04220 <br />