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1ECEDENT —NAME FIRST MIDDLE LAST 1
<br />I. Rolland Ray Smith j2Maie
<br />SEX
<br />f DATE OF DEATH (Mo., Day, Yr.)
<br />1 July 13, 1988
<br />ACE — (e.g., White, Block, American
<br />Indian, etcc.)(SQecify)
<br />t. White
<br />ORIGIN /DESCENT (e.g., Italian, Mexican,
<br />Gentian, etc.) Sp •ify) 4
<br />3 American
<br />AGE - Me,
<br />(yrs.)
<br />ya,
<br />UNDER 1 YEAR
<br />MOS. DAYS
<br />6b.
<br />I UNDER 1 DAY I
<br />HOURS : MINS.
<br />DATE OF BIRTH (Mo., Day, Yr.)
<br />Dec. 30, 1926
<br />7.
<br />CITY AND STATE OF BIRTH (N net in U.S.A.,
<br />name countr)
<br />Don Nebraska
<br />CITIZEN OF WHAT COU
<br />9. U.S.A.
<br />M (EVER MARRIED
<br />A
<br />WIDOWED, DIVQRCE (Specify)
<br />10 Married
<br />NAME OF SPOUSE (I1 wife, give ma iden name/
<br />11 Dorothy Lewandowski
<br />OCIAL SECURITY NUMBER
<br />12. 506 -26 -9347
<br />USUAL OCCUPATION (Give kind of work done during most
<br />of working life, even if retired)
<br />)30. Parts Sale
<br />KIND OF BUSINESS OR INDUSTRY
<br />Red Rooster Sales
<br />13b. (Auto ars)
<br />COUNTY OF DEATH
<br />Co . Hall
<br />14
<br />CITY, TOWN OR LOCATION
<br />lab. Wood River
<br />RESIDENCE — STATE
<br />1.5o. Nebraska J 15b.
<br />Of DEATH
<br />COUNTY
<br />Hall
<br />INSIDE CITY
<br />(Specify Yes
<br />14c. No
<br />LIMITS
<br />or No)
<br />CITY, TOWN
<br />,s Grand
<br />HOSPITAL OR OTHER INSTITUTION
<br />give street and number)
<br />14d. Lilley Sand
<br />OR LOCATION
<br />Island
<br />—Name (II not in either,
<br />Pit
<br />STREET AND NUMBER
<br />,sd. 1411 S. Sylvan
<br />If HOSP. OR INS). Indicate
<br />Outpeli•nl /Eoo.. R." . Inpatient
<br />14e. - -
<br />DOA.
<br />(Spe.ily)
<br />--
<br />INSIDE CITY LIMITS
<br />15e'y'e +' °rte °)
<br />FATHER —NAME FIRS 4TTT MIDDLE LAST
<br />16. Troy Elton Smith
<br />MOTHER — MAIDEN NAME FIRST MIDDLE LAST
<br />t7 Lillie. Mae Boroff
<br />WAS DECEASED
<br />(Y.,, no, or unh)
<br />,,Yes:
<br />EVER IN U.S. ARMED FORCES?
<br />(N yet, give won and dote. of ,snit.,
<br />12 -29 -44 7 -18 -46
<br />INFORMANT— NAME — RELATIONSHIP — MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, 2(1)
<br />oroth Smith- Wife -1411 S. Sylvan -Grand Island, NE. 688C
<br />19`' 7� y
<br />BURIAL, Cremation, Removal
<br />20a. Burial
<br />DA 16, 1988
<br />tab.
<br />CEMETERY OR CREMATORY —NAME
<br />20c. Grand Island Cemetery
<br />LOCATION CITY OR TOWN STATE
<br />20d. Grand Island, NE.
<br />EMBA M R- SIGNATURE 8 LICENSE NO.
<br />21( l—J"+w / -.? )S
<br />FUNERAL HOME —NAME AND ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />hpfel -Butler -Geddes 1123 W. 2nd, Grand Island, NE. 6880]
<br />Alsip
<br />NrI71SAI1J Du!P�Mry '
<br />DATE OF DEATH (Mo., Day, Yr.)
<br />23a.
<br />To bo Complolod
<br />I CORONER'S PHYSICIAN,
<br />or COUNT' ATTORNEY
<br />only.
<br />DATE SIGNED (Mo. Day, Yr.)
<br />24a. 7/21/88
<br />HOUR OF DEATH
<br />24b. 7:00 a. M
<br />PRONOUNCED DEAD
<br />(Mon, Day. Yr.)
<br />24c. 7/13/88
<br />PRONOUNCED DEAD (Hour)
<br />24d• 2:00 p. M
<br />DATE SIGNED (Mon, Day, Yr.)
<br />23b.
<br />1HOUR Of DEATH
<br />23c. M
<br />On the b.«. of emminotion ond/o. investigation, in my opinion death occurred at
<br />tan time. dohs and place ottd due to MM I staid
<br />T4e. (Signature o dTIN•) b. �� � t(p/1 t l ii
<br />�
<br />To Me best d my knowledge, dee* occurred at tan time, date and place and dye to Me
<br />causes) stated.
<br />23d, (Signotom and TWO II.
<br />3
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEPARTMENT OF HEALTH, IT CERTIFIES THE BELOW TO BE A TRUE COPY
<br />OF AN ORIGINAL RECORD ON FILE WITH THE STATLpE1 OF" HEALTH
<br />BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY` FOR
<br />VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />JUL 27 1988
<br />LINCOLN, NEBRASKA
<br />NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (T yps or ► 6 y
<br />rtn
<br />25. Mark Young, Deputy Hall County Attorney crag' 1 T,ri NR 68801
<br />` /7 te c
<br />REGISTRAR RECEIVED BY REGISTRAR (Mo., Doy, Yr.)
<br />!'
<br />26a. (Signature) ►
<br />27. IMMEDIATE CAUSE (ENTER ONLY ONE USE PER LINE FOR (a), (b), AND (c))
<br />PART
<br />internal bleeding
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />(b) gunshot wound
<br />DUE TO, OR AS A CONSEQUENCE Of:
<br />(c
<br />PART OTHER SIGNIFICANT CONDITIONS— Conditions contributing to death but not related
<br />ACCIDENT, SUICIDE, HOMICIDE. UNCUT,
<br />OR PENDING INVESTIGATION. (Specify)
<br />30a. suicide
<br />INJURY AT WORK
<br />(Specify Yea or No)
<br />30 . no
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH
<br />STANLF $. COOPER; DIRECTOR
<br />BUREAU OF VITAL STATISTICS
<br />266.
<br />201607769
<br />JUL 2 5 1988
<br />Intorva1 bel.eM onset and death
<br />unknown
<br />In1nol between onset end death
<br />Interval batsman Onset and death
<br />DATE Of INJURY (M.., Day, Yr.)
<br />30b. 7/13/88
<br />MACE OP INJURY— M home, fans, afoot, factory,
<br />*thins building, els. (Spotify)
<br />30f sand pit
<br />PART III. IF FEMALE, WAS THERE A
<br />PREGNANCY IN THE PAST Z MONTHST
<br />Yes 0 No ❑
<br />HOUR Of INJURY
<br />7 00 a.
<br />30. M
<br />DESCRIBE HOW INJURY OCCURRED
<br />AUTOPSY
<br />(Sp«ily Yes or NO
<br />28. yes
<br />30d Decedent shot h
<br />LOCATION STREET OR 1.4.0. No.
<br />10 Lilley Sand Pit, Woo
<br />WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER
<br />(Specify Yes or Ne)
<br />29. yes
<br />imself
<br />CITY OR TOWN STATE
<br />d River, NE
<br />1
<br />
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