|
404
<br />vow.e.;. QilUNl4t &rtk)12u SG?rferv�:�sta((ri�1t111iiiii3
<br />�a,� STATE OF NEBI
<br />olt;!'". eIcwoD2aat9(9Y[;I.Fftaxca atsr44'i'rl2ta
<br />;jai
<br />arl
<br />�itlta444�i17i��44 f4�(%I.W
<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 />1/15/2021
<br />LINCOLN, NEBRASKA
<br />202102549
<br />SARAH BOHNENKAMP
<br />ASSISTANT 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 />21 00186
<br />1. DECEDENTSNAME (First, Middle, Last, Suffix)
<br />Annette Arlene Smith
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 8, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />66
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 5, 1954 <.
<br />7. SOCIAL SECURITY: NUMBER
<br />505-76-9463
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />817 S Vine
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />9d, STREET AND NUMBER.
<br />817 S Vine'
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE: CITY LIMITS'
<br />YES Q NO
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />0 Married, but separated 0 Widowed El Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Carl Stueven
<br />12. MOTHER'S -NAME (First, Middle,
<br />Edna Schimmer
<br />Malden Surname)
<br />13. EVER IN U.S ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Robert Stueven
<br />14b. RELATIONSHIP TO DECEDENT`
<br />Brother
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑Donation
<br />Cremation CI Entombment
<br />Removal Q Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />January 11, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Colonial Chapel Cremation Center
<br />CITY 1 TOWN
<br />Lincoln
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />1e. PART I. Enter the chain of events- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Inc.IAdd additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />a) Undetermined Natural Causes
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting',
<br />in death)
<br />Sequentially list conditions, If
<br />any, leading to the cause listed
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />(disarm) or injury that initiated
<br />the events resulting in death)
<br />LAST
<br />17b. Zip :Code
<br />68803.•
<br />APPROXIMATE INTERVAL
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />onset to death
<br />DUE TO, OR ASA 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 />19. WAS MEDICAL EXAMINER`
<br />OR CORONER CONTACTED?
<br />EI YES ❑ NO
<br />20. IF FEMALE:
<br />® Not program within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant. but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown H pregnant within the past year
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO ..;, .
<br />225. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY,,, STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />,gad. TO HIM beet of my knowledge, death occurred at the time, date and place
<br />and due tote causes) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />January 8, 2021
<br />PGODE
<br />24b. TIME OF DEATH
<br />Approx. 09:00 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />January 8, 2021
<br />24d. TIME PRONOUNCED DEAD
<br />12:00 PM
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred et
<br />the time, data and place and due to the cause(s) stated. (Signature end tine)
<br />Dave Medlin, Hall County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES` ®NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO Q YES
<br />❑ N
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Dave Medlin, Hall County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 12, 2021
<br />1
<br />CD
<br />(0
<br />IND
<br />C]
<br />
|