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'4 okAgaw, e 111., " "'.,.A.a ttsut , " ,.ff .atidtlex.m ?.. eee. .A■■,, y dedsxfiatitM,, M °C STATE OF NEBRA' WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA 8 $ CERTIFIES THE DOCUMENT BELOW TO BE <A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 5/17/2016 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF H CERTIFICATE 0 F DEATH EALTH AND HUMAN SERVICES A atiftel STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES - F4 E 0 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Sharon Kay Smith 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Kearney, N ebraska 7. SOCIAL SECURITY NUMBER 506 -46 -0706 8b. FACIL1TY -NAME (If not Institution, give street and number) CHI Health St. Francis 9a, RESIDENCE -STATE Nebraska 1.3. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No Z 15. METHOD OF DISPOSITION 10- ❑ Burial ❑ Donation E Cremation ❑ Entombment :0 Removal ❑ Other.(Specify) DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) idisease Or Injury :that initiated:. the events re$010"0 in death) ; DUE TO, OR AS A CONSEQUENCE OF: LAST; d) 20. IF : FEMALE: E Not pregnant 'within past year ❑ Pregnant at time of death ❑ Not pregnant, but prepaid within 42 days of death ❑ Net pregnant, but pregnant 43 days to 1 year before death ❑ Onknown if psegnam s thin the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT • DYES D NO 25.`010 TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO ID PROBABLY ❑ UNKNOWN 5a. AGE Last Birthday (Yrs.) 74 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9b. COUNTY Hall 9d. STREETAND NUMBER 4146 Manchester Road 1Oa. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Clarence Arthur Shubert Verna Irene Cox Middle, Maiden Surname) 16a. EMBALMER-SIGNATURE Katie M. Smydra 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska 22b. TIME OF INJURY 14a. INFORMANT -NAME Ronald Lee Smith 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide 0 Could not be determined 23b. DATE SIGNED (Mo., Day, Yr.) Mav11, 23c. TIME OF DEATH 11:06 AM . DATE OF DEATH (Mo., Day, Yr.) May 10, 20'16 d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) ay ::,e; Anderson, MD MOS., 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 1 SIGNATURE 1 3 _ Coo +v 6b. UNDER 1 YEAR 8a. PLACE OF DEATH HOSPITAL E Inpatient ❑ER/Outpatient ❑'DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand Island 10b. NAME OF < SPOUSE .(First, Middle, Last, Suffix) If wife, give maiden name.: Ronald Lee Smith' DAYS 9e. APT. NO. 2. SEX Female Sc. UNDER 1 DAY HOURS MINS. 8d. COUNTY OF DEATH Hall 9f. ZIP CODE 68803 16b. LICENSE NO. 1454 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska CAUSE OF DEATH (See instructions and examples) S PART I. Enter the chain Of events- -diseases, injuries, or complications -that directly caused the death. DO' NOT entertenninal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines 4 necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Abdominal Compartment Syndrome disease or condition resulting APPROXIMATE :iNTERV onset to death Days in death) Sequentially fist ctittditions, if any, leading to tile Cause fisted DUE TO, OR AS A CONSEQUENCE OF: b) Small Bowel Obstruction onset to death. Days onset to death 18: PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Acute hypoxic Respiratory Failure, Atrial Fibrillation With Rapid Ventricular Response, Urinary Tract Infection, Acute Renal Failure 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other(Specify) 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? E YES ONO 3. DATE OF DEATH (Mo., Day, Yr.) May 10, 2016 6. DATE OF BIRTH (Mo., Day, Yr.) August 2, 1941 9g. INSIDE CITY LIMITS: Q YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) May 12, 2016 17b. ZIp Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO . 24b. TIME OF DEATH 24d. TIME PRONO cap DEAD 24e. On the basis of examination and /or investiga ion, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 28b. DATE FILED BY REGISTRAR (MO-, Day, Yr.) May 12, 2016