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<br />( STATE OF NEBRASKA_
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />11/17/2021
<br />LINCOLN, NEBRASKA
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<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 />t DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Cynthia Ann Smith
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-74-5773
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />68
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />The Heritage at Saoewood
<br />Se. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />❑ ER,Ou patient
<br />❑ DOA
<br />9e. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 15263
<br />3. DATE OF DEATH (Mo., Day, NW
<br />November 2, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 12, 1953
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Homs
<br />® Other (Specify)ASSISTED LIVING
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9d. STREET AND NUMBER
<br />4363 W. Capital Ave
<br />10a MARITAL STATUS AT TIME OF DEATH ® Marded 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g INSIDE CITY LIMITS::
<br />® LES ❑ O
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Dennis Arthur Smith
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert Green
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />10 Burial EiDonation
<br />❑'Cremation ❑Entombment
<br />❑ Removal ❑ Other (Specify)
<br />12. MOTHER'S -NAME (First, Middle,
<br />Viola Anna Rudnick
<br />14a. INFORMANT -NAME
<br />Dennis Arthur Smith
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />18b. LICENSE NO.
<br />1495
<br />Malden Surname)
<br />14b. RELATIONSHIP TO DECEDEN
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.)
<br />November 13, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />CITY I TOWN
<br />Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />17b. Zip Cods
<br />68801
<br />15. 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 ventdcular 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) Cardiopulmonary Arrest
<br />IMMEDIATE CAUSE (Phial
<br />die*** or *minion resulting
<br />in death)
<br />Sequentially list Conditions, H
<br />•ny, leading to the cauee listed
<br />on lino a.
<br />Ental the UNDERI.YING CAUSE'
<br />(disease or Injury that Initiated
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />b) Malnutrition
<br />APPROXIMATE INTERVAL
<br />onset tot***
<br />Several MinuteS
<br />onset to death
<br />Several Months
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Alzheimer's disease with early onset dementia
<br />onset to death
<br />1 Year
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART H.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 />❑ YES ® NO
<br />20. IF FEMALE:
<br />® Not Preempt *thinnest Year
<br />❑ Pregnant at ems *death
<br />0 '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 if pregnant 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 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 />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE, QF INJURY -At home, farm, street, factory, office building, construction site, etc, (Spec((')"
<br />22d. INJURY AT WORK?
<br />❑ YES L..1 NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION' OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 2, 2021
<br />CITYfTQWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />November . 2021 10:43 AM
<br />)ad. To the bestof myknowledge, death occurred at the time, date and piece
<br />and due to the Causes) stated. (Signature and Title)
<br />Thomas F. Werner, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES al NO 0 PROBABLY ❑ UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or *vestige Ion, In my opinion death KCCtitred at
<br />the tem, date and place and due to the cause(s) stated. (Signature end Tide)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES 1NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES 0 NO;
<br />27. NAME, T)TLA AND ADDRESS OF CERTIFIER (Type or Print
<br />Thomas F. Werner, MD, 810 North Diers Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />04-44-ABad rc er✓t. �sz _
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />November 12, 2021
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