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-C M n h o o <br />M m CA � � m �� � �� M O �? <br />(7 c 1� ►-+ d -n O <br />fh C=) ;y F� 1 <br />V\ A rn "� D LT7 C= <br />00 0 c7p I <br />O 01 <br />N 1-Z C <br />4) CA En <br />WE <br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAMSERVICES <br />SYSTEM, /T CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECD C1N:F"•W►TH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT/ST�;ffV*0N WHIGR IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />lbill <br />DATE OF ISSUANCE AAR 200104344 N' <br />AIL YS. COOPER- <br />JAN 92001 ASSWAWS WEREdeTRAR. <br />LINCOLN, NEBRASKA HEALTH AND H6*A-N, SERVICES SYSTEQ- <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES-FINANCE AND SUMRT <br />VITAL STATISTICS <br />CFRTTFICATF. OF T)FAT" <br />l DECEDENT -NAME FIRST MIDDLE LAST <br />2 SEX <br />3. DATE OF DEATH 'Month. Day. Year) <br />Aron Wesley Smith <br />Male <br />January 1, 2001 <br />4, CITY AND STATE OF BIRTH Whol in USA, name country, <br />58 . AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH /Month, Day. Year) <br />Litchfield, Nebraska <br />(Yrs177 <br />Sb MOS DAYS <br />5c. HOURS MINS <br />January 21, 1923 <br />7. SOCIALSECURTIY NUMBER <br />8a. PLACE OF DEATH <br />508 -14- 1012 <br />HOSPITAL: � Inpatient OTHER ❑ Nursing Home <br />26a. <br />❑ ER Outpatient ❑ Resdence <br />8b. FACILITY Name 111 not institution, give street and number) <br />St. Francis Medical Center <br />❑ DOA ❑ Other (Specd,, <br />8c. CITY. TOWN OR LOCATION OF DEATH 80. INSIDE CITY LIMITS <br />Be. COUNTY CF DEATH <br />Grand Island Yes ® No ❑ <br />Hall <br />9a. RESIDENCE -STATE <br />9b COUNTY <br />9c. CITY, TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including Dp Code) <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />4519 E. Bismark Rd. 688 <br />1Yes8] ❑ <br />No <br />10. RACE - (e.g., While. Black. American Indian. <br />11. ANCESTRY le. g.. Italian. Mexican. German, etc) <br />12 ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE tit wife. give maiden name) <br />eta/ lSOecityl White <br />ISpeatyl Irish <br />NEVER DIVORCED <br />MARRIED <br />Shirley Fay Beneires <br />14a. USUAL OCCUPATION (Give kind of work done during most <br />14b KIND OF BUSINESS INDUSTRY <br />15. EDUCATION ISPecity only highest grade completed( <br />it <br />of working lit, eevvna�Gedr <br />ll <br />Insurance Company <br />ElementaryO S20ndary 10121 College I1 -4 or 5•I <br />1L <br />16. FATHER -NAME FIRST MIDDLE LAST <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Aaron Smith <br />Nellie Brewer <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a INFORMANT - NAME <br />�Yes: uWWd Z BS 3ew26 194services, 28 -1946 <br />Shirley F. Smith <br />_b INFORMANT MAILING ADDRESS (STREET OR R IF 0 NO.. CITY OR TOWN. STATE. ZIP( <br />4519 E. Bismark Road, Grand Island, NE. 68801 <br />20. EMB LINER - SIGNATURE 8 LICENSE NO '` <br />2/a METHOD OF DISPOSITION <br />21b. DATE 21c. <br />CEMETERY OR CREMATORY NAME <br />M <br />Burial ❑ Removal <br />Jan- 4, 2001 <br />Grand Island Cemetery <br />FUNERAL HOME - NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- Butler - Geddes <br />❑ Crematlob ❑ Donation <br />Grand Island, NE. <br />FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, ZIP) <br />[210 <br />1123 West Second, Grand Island, NE. 68801 <br />m. IoI. r.�xu Icn Interval between onset and deam <br />PART <br />1 Ia) (L1 .il/I /.�/�•?O.� 7 /'i7 /t`i/�C /�i/(L./ <br />DUE TO, OR AS A CONSEEJODUE��NC`E OF <br />- Interval between onset and death <br />(b) <br />DUE TO. OR AS A CONSEQUENCE OF <br />Interval between onset and deal, <br />Ic) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />PART <br />III IF FEMALE. WAS THERE A <br />24 AUTOPSY <br />25 WAS CASE REFERRED TO MEDICAL <br />PREGNANCY <br />II <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER' <br />(Ages 10 -54) Yes No <br />yes F <br />Vas M NO <br />26a. <br />26b. DATE OF INJURY IMO. Day Yr.J <br />26c HOUR OF INJURY <br />DESCRIBE HOW INJURY OCCURRED <br />F] Accident F Undetermined <br />126d. <br />M <br />❑ Suicide n Pending <br />26e. INJURY AT WORK <br />261 PLACE OF INJURY - At home . farm. street. factory <br />budding. <br />26g. LOCATION STREET OR R.F.O. NO. CITY OR TOWN STATE <br />Homicide InveSligahOn <br />Yes[] No ❑ <br />o ce etc l pecr <br />27a. DATE OF DEATH /Mo. Day YrJ <br />28a. DATE SIGNED tMo.. Day. Yr.) <br />28b TIME OF DEATH <br />> <br />= J <br />27b. DATE SIGNED tMo. Day. Yr.) <br />27c TIME OF DEATH <br />28c. PRONOUNCED DEAD tMo. Day, Yr) <br />28d. PRONOUNCED DEAD (Hour) <br />$ <br />M <br />v <br />M <br />27d To the best of my knowledge. ot ime, d e a I and due Io the <br />288. On the Oasts 01 examinaaon and'IX investigation, In my opinion tleath occwretl at <br />causelsl stated. <br />s <br />the time, date and place and due to the cause(s) stated. <br />(Signature and Title ) 10 <br />(Si nature and Title <br />29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />jQ_1ES ❑ NO ❑ UNKNOWN <br />❑ YES �NO <br />❑ YES NO <br />31 NAMt AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) (Type or Pint) <br />David R. Colan M.D. 729 N. Custer, <br />Grand Island; NE 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRg /Mo., Day Yc) <br />JAN ids 2001 <br />II - <br />LOT THREE(3) IN BLOCK THREE, LAKE DAVIS ACRES, HALL COUNTY, NEBRASKA <br />,e. <br />S- <br />0 <br />