|
WH▪ EN 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 ift
<br />DATE OFISSUANCE
<br />2/21/2919
<br />LINCOLN, NEBRASKA
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Jerry Glenn Smetter
<br />\, ((, .1, . r yi 4i$t s <ix 11 14/G L ;to rl f i. _.. : t1I1 f i $ 8% S fPV174 i y ,
<br />�' c�8((h'Noti,��`C��P��Q��$ua6�` ��;t9/��,,.ep,�.3�11A, „R.,,Iia,��aetr�.,.,'lAI,�(98�t.asa..I$tx„�I.E�.III,�',s%tit%,aaa.Ix,,,,,,R,(,s4,'�
<br />,Jt( CTATF AF NFRRACKA
<br />1de,miasl'X �t d
<br />` URNES r - "0.GE ix(4lii sm a xrthtiYiltea ratty
<br />Dye? x iNkrp, ,Ut �gYA�J+�
<br />n:`i 6iih'J �il )r Ila M l �ai�u4 tag.11at't,rtu
<br />MN13f , H, 1 r"uuii��Ct(',p45'1"
<br />���1�iyi�awl�yN r .....,.
<br />2 01 9 0 6 7 9 ASSISTRANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />kart AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Goehner, Nebraska
<br />.t9 7. SOCIAL SECURITY NUMBER
<br />' _ 505-50-98$0
<br />0
<br />5a. AGE - Last Birthday �b. UNDER 1 YEAR
<br />b. FACILITY -NAME (If not Institution, give street and number)
<br />UNMC
<br />5 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68198
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />105 W. Cedar St.
<br />g 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />-o
<br />2 ❑ Martted, but separated ❑ Widowed ❑ Divorced 0 Unknown
<br />d 11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Frank Benjamin Smetter
<br />9b. COUNTY
<br />Hall
<br />(Yrs.) MOS. DAYS
<br />77 t
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Doniphan
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />February 5, 2019
<br />Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mt Day, Yr.),
<br />HOURS I MINS.
<br />April 27, 1941
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68832
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sandy White
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Gladys Opal Huffman
<br />a. 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />I(Yes, No, or Un9.) NO
<br />15. METHOD OF DISPOSITION
<br />g 0 Burial ❑ Donation
<br />c ® Cremation 0 Entombment
<br />❑Removal [] Other (Specify)
<br />14a. INFORMANT -NAME
<br />Sandy Smetter
<br />14b. RELATIONSHIP TO DECEDENT.
<br />Spouse
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo, Day, yr.)
<br />February 6, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Heafey-Hoffman-Dworak-Cutler Omaha
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, Stats)
<br />oZabka-Perdue Funeral Home. 410 Jackson. Seward. Nebraska
<br />13
<br />m
<br />r
<br />STATE
<br />Nebraska
<br />17b.7Jp Code
<br />68434
<br />CAUSE OF DEATH (See instructions and examples)
<br />6 le. PART I. Enter dirt chain of events. -diseases, Injuries, or complications -that directly canted the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, to verdrlcular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Complications Of Subarachnoid Hemorrhage
<br />l IMMEDIATE CAUSE (Final
<br />in
<br />e7
<br />disease or condition resulting
<br />In death)
<br />Sequentially list condittods,
<br />any, _Seeding to the cause listed
<br />on linea ---
<br />9
<br />sr
<br />S Enter the UNDERLYING CAUSE
<br />(diseaseorinjurythet initiated:
<br />the events resulting In death)
<br />LAST
<br />m
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />5 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />g 20. W FEMALE;
<br />0 Not pregnant within past year
<br />t
<br />ca ❑ Pregnant at time of death
<br />Cure ❑ Nat pregnant. but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown If piegnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be detefmined
<br />2/b. IF TRANSPORTATION
<br />© Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />INJURY
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />3 Weeks
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES El NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES 0 N
<br />2 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />re
<br />v
<br />Pr
<br />22d. INJURY AT WORK?
<br />DYES ONO
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />v 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />N
<br />0
<br />23*. DATE OF DEATH (Mo., Day, Yr.)
<br />February 5, 2019
<br />CITY/TOWN
<br />STATE ZIP CODE
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />February 13. 2019 03:33 PM
<br />• 3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Elizabeth M Miles, MD
<br />25. DID TOBA ..t USE CONTRIBUTE TO THE DEATH?
<br />0 YES 0 NO ka PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ya;O C
<br />I 1• J
<br />g"a
<br />cc Z z 2N- On the basis of examination and/or investigation, In my opinion death occurred at
<br />BO u the time, date and place and due to the cause(s) slated. (Signature and Title)
<br />g 5
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUN
<br />ED DEAD
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ®NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Elizabeth M Miles, MD, 986435 Nebraska Medical Center, Omaha, Nebraska, 68198
<br />28a. REGISTRAR'S SIGNATURE
<br />.lJ..£_• I--/.' T o c.�-a `ter•"+1�'-
<br />26b. WAS CONSENT GRANTED/<^
<br />Not Applicable If 26a is NO ❑ YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (MO.Day,- Yr.)
<br />February 13, 2019
<br />
|