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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE ''A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />12/5/2017
<br />LINCOLN, NEBRASKA
<br />2018 ti 4012
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Coe
<br />STANLEY S. OPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Gayle Ann Smith
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Ord Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505 -74 -7223
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Madonna Rehatriiitation Hospital - Lincoln
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes,
<br />No Or Unk.) NO
<br />15. METHOD OF<EFBPOSITION
<br />❑ Burial ❑ Donation
<br />E Cremation ❑ Entombment
<br />0 Removal _❑ Other(Specify)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />60
<br />9b. COUNTY
<br />Hall
<br />I Oa. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married
<br />❑ Married, but separated; ❑ Widowed E Divorced ❑ Unknown
<br />5b. UNDER 1 YEAR
<br />MOS. 1 DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />9d. STREET AND NUMBER
<br />203 W. 15th Street
<br />16a. EMBALMER-SIGNATURE
<br />Not Embalmed
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />9e. APT. NO.
<br />MINS.
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />David Allen Smith
<br />16b. LICENSE NO.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 18, 2017
<br />6. DATE OF BIRTH (Mo. Da
<br />May 11, 1957
<br />9f. ZIP CODE
<br />68801
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska
<br />Yr.)i
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Lincoln 68.510
<br />8d. COUNTY OF DEATH
<br />Lancaster
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9g. INSIDE CITY LIMITS
<br />EI YES ❑ NO
<br />10b. NAME OF SPOUSE (First, , Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S - NAME (First, Middle, Last, Suffix)
<br />Gaylord Hank
<br />1 12. MOTHERS -NAME (First, Middle,
<br />Lois Fillinger
<br />Maiden Surname)
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />16c. DATE (Mo., Day Yr.)
<br />November 28, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the Chain of eve ds -- diseases, injuries, or complications -that directly caused . the death. 00 NOT enter terntlnal events such as cardiac arrest,
<br />fEepirat0ry arrest, orveh tfidular 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) Pneumonia
<br />disease or condition resWeng
<br />APPROXIM ATE'(NTERVAL:
<br />onset to death
<br />4 Days
<br />in death)
<br />Seglentiallyilst conditions, if
<br />any, leading to thecause listed:
<br />on line a
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Chronic Obstructive Pulmonary Disease
<br />onset to death
<br />5 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE " c) •
<br />(disea initiated :.
<br />onset to death
<br />the events resulting in death)
<br />LAST::
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF : FEMALE:::
<br />E Not ptegnantwithin past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant,, but pregnant within 42 days of death
<br />❑ Hot pregnant- but pregnant 43 days to 1 year before death
<br />❑ Unknown ifpregnantwithin the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />fld.INJURYATW! RK?
<br />❑YE$ ❑NO
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />3 a. DATE OF DEATH (Mo., Day, Yr.)
<br />Npvemt er;16, 2017
<br />X 23b. DATE SIGNED (Mo., Day, Yr.)
<br />w
<br />z November 28, 2017
<br />u a
<br />0 3d. To the best of my knowledge, death occurred at the time, date and place
<br />.E c and due to the cause(s) stated. (Signature and Title)
<br />M � .
<br />• John! H Rudersdorf, MD
<br />23c. TIME OF DEATH
<br />04:04 PM
<br />25. D)O TQBACCO'USE CONTRIBUTE TO THE DEATH?
<br />0 YES ❑ NO ❑ PROBABLY E UNKNOWN
<br />22b. TIME OF INJURY
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Gould not be determined
<br />28a. REGISTRAR'S SIGNATURE
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other!ISpecify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN "CONSIDERED?
<br />E YES ■ NO
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CITY /TOWN
<br />STATE
<br />"ZIP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCE DEAD
<br />24e. On the basis of examination and /or investiga ion, in my opinion death occurred at
<br />the time, date and place and due to The causes) stated. )Signature and Title)
<br />26b. WAS CONSENT GRANTED? .
<br />Not Applicable if 26a is NO ❑ YES ENO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />John H. Rudersdorf, MD, 1500 S 48TH ST, STE 800, Lincoln, Nebraska, • X506
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 30, 2017
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