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4 <br />\ M n n <br />M M A <br />T <br />n n z rn X O m CD <br />M V1 CNJ5,. C D N G^D <br />R 2 <br />C= D. <br />O N <br />'fir- O y <br />CD <br />r n 111, r Q•' 23 <br />C- r L <br />v� c <br />CD (10 � Cp �. <br />CAD C2 <br />WHEN THIS COPY CARRIES TIC RAISED SEAL OF THE NEBRASKA HEAL Alfi&fl[IINAN SERVICES } <br />SYSTEM, IT CERTF:IES THE BELOW TO BE A TRUE COPY OF THE O_ EE BN FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, W _ WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS - = -- <br />DATE OF ISSUANCE �j�j j]r� (� <br />oC �, 9 11�j1 �/ IJ V O ! - _ = i OOOPER is fA <br />LINCOLN, NIBJSKA HEALfHAND ,M-SERVICEISYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUNANSF,RftEtTKWCE*M SUPPORT <br />VrTAL STATISTICS <br />CERTIFICATE OF D1RA7 � -- <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX <br />3. DATE OF DEATH tMorlM. Day, year) <br />Chester Gale Smith <br />Male <br />September 10, 1998 <br />4. CITY AND STATE OF BIRTH tdnot in U.S.A.. name Country) <br />Sa. AGE -Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />0. DATE OF BIRTH lMOrA Day. Yearl <br />so. MOS. I DAYS <br />Sc. HOURS' MINS. <br />Ainsworth, Nebraska <br />(Yrs.) 65 <br />August 09, 1933 <br />7. SOCIAL SECURTIY NUMBER <br />Sa. PLACE OF DEATH <br />450 -40 -0133 <br />HOSPITAL: ❑ Inpatiem OTHER: Nursing Home <br />-- -- <br />a ER Otdpatient Residence <br />W. FACIUTY - Name _ _.. _ /d not msN ,, give sheet and number) <br />_ <br />St. Francis Medical Center <br />DOA Other (Specdy, <br />Be. CITY. TOWN OR LOCATION OF DEATH <br />Sd. INSIDE CITY LIMITS <br />Be. COUNTY OF DEATH <br />Grand Island <br />Yes ®,,b <br />Hall <br />9a. RESIDENCE - STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER tlncludng Zo Code; <br />ga. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />3103 Kennedy Circle, 68803 <br />Yea IN No <br />10. (s�.gN., While. Black. Amsnican kMian, <br />t1. ANCESTRY (e.g.. Italian, Mexican. German, etc) <br />t2. MARRIED ❑ WIDOWED <br />NAME OF SPOUSE O wile. give maiden name) <br />aR�AC�ES- <br />VV[Itt`C"I <br />rican <br />NEVER DIVORCED <br />ARRIED <br />113. <br />Joan Campbell <br />1N. USUAL OCCUPATION /Giro kind ot work done dude most <br />p�yt �yr� evenar/ntasdl <br />l elfaif Irate <br />14b. KIND OF BUSINESS INDUSTRY <br />Grocery Store <br />15. EDUCATION (Sped only craft cartpNlW) <br />EMnalty or Secondary (0.12) College (1.4 or 5.1 <br />19. FATHER -NAME FIRST MIDDLE UST <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Vernon Smith <br />Dorotha Fink <br />19, WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT - NAME <br />(Y no. or tmk.1 III yes. Ive war and dates of services) <br />i'es 152 -1956 <br />Joan Smith <br />19b INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE. ZIP) <br />3103 Kennedy Circle, Grand Island, Nebraska 68803 <br />20. MLRi- SIGjNR LICENS <br />2L. METHOD OF pSPOSIT10N- <br />21b. DATE - 21e. <br />CEMETERY OR CREMATORY NAME <br />,sti.,,�i�" �,a�, �a T <br />Q au,w R.moYal <br />09/14/1998 <br />Westlawn Memorial Park Cemetery <br />-Jft. FUNERAL HOME - NAME 091 <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- Butler- Geddes Funeral Home <br />cr«nMgn oonaton <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE. ZIP) <br />1123 West Second Grand Island, Nebraska, 68801 -5899 <br />LJ. MM VIN It VR t IEN I EM uNly LINE I;AU�1� PYI1LINtt- UK- +aLrfYi. APIV ICb' "- I InIoNal DO~ MNM and death <br />PART _ _ __ <br />I <br />tai ('arr�i �n groat -1-- <br />UUE IU. UH AS A CONSEQUENCE OF I Interval between onm and death <br />I <br />IN <br />I <br />DUE TO. OR AS A CONSEQUENCE OF I Imerval henwen Cni and death <br />j <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A <br />24 AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />If <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />)Ages 10 -541 Yes No <br />Yes No R1 <br />Yes NO <br />26a <br />26b. DATE OF INJURY /Mo.. Day. Yrl <br />26c. HOUR OF INJURY <br />28d. DESCRIBE HOW INJURY OCCURRED <br />0 Accident ❑ Undetermined <br />M <br />Suicide 1:1 Pending <br />260, INJURY AT WORK <br />261. PLACCE%, INJURY �11t ho71p, )arm, street factory <br />build <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />Yes ❑ No ❑ <br />o�c 3Pacn)7 <br />27a. DATE OF DEATH /MO. Day. Yrl <br />28a DATE SIGNED (Mo.. Day. YrI <br />28b. TIME OF DEATH <br />b <br />Spnt-ernhar- 95 <br />M <br />98 <br />27b. DATE SIGNED IMO.. Day. Yr! <br />27t. TIME OF DEATH <br />28t P NOUNCED DEAD /MO.. Day, cl <br />2Bd. PRONOUNCED DEA /HOUrI <br />ih <br />r <br />� ` y <br />N <br />21 <br />M <br />21 <br />M <br />27d. To the best d my knowledge, death occurred at the time, date and place and due to the <br />n the basis d ;Rain vestipa07. my opinion death occumed at <br />cauaelsl stated. <br />v a <br />the time. date and dad uu sl ted. <br />(Signature and Title <br />5 nature and TO <br />29. DID TOBACCO <br />USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b CONSENT GRANTED? <br />YES NO IX UNKNOWN <br />� YES EX NO <br />El YES ® NO <br />O - nnv nvvnc..- - .... . lr-IVrnn,VVnVnCn�nnTJM1Ann Vn VVV1YIT I.IIVnIVCTI /ryPe Or r/rIl <br />1 <br />