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<br />-��-STATE OF NEBRASKA i_„-
<br />iNHEN TlilS COPY CARR1.IES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO .
<br />SEI'llA TRt1E COPS' OF THE ORIGINAL RECORD ON FILE WITH THE NEBI'lRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY`FOR VITAL RECORDS
<br />2122/202 •.' 1. ;�t "` It `�A
<br />QQ Q
<br />2 O 2 2 O 1 1 d V SARAH BOHNENKAMP
<br />LINCOLN, NESS
<br />ASSISTANT STATE' REGISTRAR
<br />DEPARTMENT OF HEALTH' .; ..
<br />AND HUMAN SERVICES
<br />;.;
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH 2202623
<br />:1 I1
<br />:PtAME (1~iCat, Middle, Last, Suffix)1.
<br />DECEpENTS-.11
<br />2. SEX
<br />3. GATE OF DEq?H ()ot, Day Yr«{:::
<br />Elaine Fi" Smith
<br />Female
<br />Februa 1 2Q22
<br />4. CITY AND STATE QA TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Se. AGUE - Last Birthday
<br />8b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />. 6. DATE OF BIRTH {Irllb., tray, Yr)
<br />:::.
<br />.,... !
<br />(Yrs.)
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.11
<br />I'll, 11Minden
<br />Nebraska
<br />75 ::
<br />October24 1946a
<br />i $I ,::I SECI►#2IT Y NUf1tI.8 >I.:
<br />8a PLACE Ott DEATH
<br />203-18.45.341
<br />HOSPaAT] inpatient OTHER ®Nursing Home/LTC 1(iyspFde FaSiiRyt.
<br />:
<br />ap]
<br />.
<br />ERlOutpatlentI'll
<br />❑ Decedent's Home
<br />I
<br />.
<br />8b. FACILITY -NAME jif 40 Institution, give street and number)_
<br />;>1
<br />:: CHI Health St. Francis
<br />❑ DOA ❑ Other (Specify)
<br />0
<br />6
<br />8c. CITY OR 11TOUitN11- OF , .__ (Include Zip Code)
<br />6d. COUNTY OF DEATH
<br />%.
<br />.1
<br />.1
<br />Grand islarid E)8808
<br />*0
<br />9a. RESIDENC94TATE
<br />11
<br />1.Heli
<br />9b. COUNTY ..
<br />Ise. CITY OR TOWN
<br />I I'llAQ619A
<br />Nebraska ' !
<br />Hall
<br />Grand Island
<br />9d 67REET Af(tt NUM13Bfi 8. APT. NO. 9f. ZIP CODE 9g, INSIiE C1 E Y 1IM1Te
<br />1.w+
<br />Ebb E Ashton Avs%: 68801 .... [ t .
<br />,
<br />10a: AAARITAL STATUS AT TIME OF DEATH []Married Never Married ii)L:NAME it.SPOUSE (First, "Middle, Last, Suffix)If wife, give maiden name. '
<br />v
<br />q�
<br />❑ Married, but separated []Widowed ❑ Divorced '❑ Unknown
<br />11. FATHER'S -NAME .1FIm.t, Mid1.dle, Last, Suffix) 12. MOTHER!"AME (First, Middle, Maiden Sumerian)
<br />LsRoy $meth K ridav
<br />"I I.11.
<br />13. EVER IN U B; ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME: 14b. RELATION limp TO D1»WENi
<br />(Yes, No, or Unk) No Roselle Smith Sister -
<br />16. METHOD OF DISPOSITION
<br />16a. EMBALMER-SIGNATURE1.
<br />16b. LICENSE NO.
<br />18a DATE (Mo Day Yr.) .
<br />,'
<br />❑;fiuHal ❑Dtrnat�on
<br />Not Embalmed
<br />.
<br />februarY 1i3,2.
<br />❑ Entombment
<br />, 111-11i0remailon
<br />❑'Rsmtwal ❑1.4thertSj3ecify)I
<br />16d. CEMETERY, CREMATORY OR OTHER# LOCATION CITY / TOWN STATE
<br />11
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />f
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />1� Zip Coda
<br />Ali F1.aithsunerai 1#ome, 2929 S. Locust Street, Grand IslandI, 1.IVebraSka
<br />888{31
<br />I,
<br />CAUSE OF DEAiH'' Inst B n rrd xam I s
<br />19. PART 1. Enter the chain of events. diseases, Injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest, , APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines a necessary. ;
<br />IMMEDIATE CAUSE:1. : ona� todeattPl;::
<br />iM(r1ptATECAtI$EtRimat &! Rt;spiratory Failure < 9 DeI.Y
<br />11.
<br />W4ea66 of bbddaton resuafng
<br />-1 11 I":.
<br />In deti8i) DUE TO, OR AS A CONSEQUENCE OF: IX . onset to death
<br />I
<br />:.1
<br />eegaentlany uatceI t e_Ir ,i : b) metastatic endometrial cancer > 1,Year�
<br />m
<br />.,
<br />any, loading to the oause lkated". .
<br />an aI.nsa DUE TO, OR AS A CONSEQUENCE OF: onset tRf#eath '-
<br />: +
<br />Entartbe tJNOERL:YING CAUSES C)
<br />'
<br />(diesuefrrlmjurythatlmitlateA. :. :;: ; -
<br />"
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />LAST
<br />d)
<br />,b
<br />:;
<br />i8 PARTS OTHE;iR SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resawn9 Iii the underlying cause given in PART
<br />I. 19. WAS MEDII"iAly:E3CAAIIiNEft '
<br />fi
<br />m6rbld t1bBtltY, diattsies, coronary artery disease
<br />OR cORONERCOWrACT(3?
<br />11.1
<br />1.11
<br />I
<br />❑ e Iz NO
<br />20 IF,FEMALE, !
<br />21a. MANNER OF DEATH Ftp IF TRANSPORTATION INJURY 21c.
<br />WAS AN AUTOPSY PERF ?.
<br />11.
<br />".:3k
<br />�
<br />®.Plof pra(jnant,wlthutpast year
<br />`® Natural ' ❑ Romiet$e ❑ flrhr6r/Operator
<br />❑ YE$ ® NO
<br />:v
<br />�:
<br />1-1 Pngdartiat Wii 01A dt ..
<br />y :::
<br />❑. Accident ❑ Pemding tnvaatlgatu+it Q Pasttehger
<br />WERE AUTOPSY plti#IINGS AtfAE1 A
<br />4r
<br />❑ tlat prsgnani:but pifthent within 42 days of death
<br />fiedestrian 21d.
<br />❑ Suicide ❑ could not be deterinine ❑
<br />�7
<br />❑ Not pregnant. but pregnant 43 days to 1 year before death
<br />❑ Other (Specify)
<br />TO COMPLETE causE of DEATH?
<br />";:: $_
<br />a Unknown H pregnant within the pest year
<br />❑YES ❑ NO
<br />B
<br />$2a HATE OF IW i(iRY (Mor pay, Yr.)
<br />22b. TIME OF INJURY
<br />22c PLACE pF INJURY=At home, faith, street, factory, office building, construction aft el {SpseNyr)
<br />"
<br />22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />m
<br />V
<br />:. ❑YES .❑NO,
<br />:'
<br />t`
<br />'w tE AT10N1. OF INJURY •STREET & NUMBER, APT.NO. CITY/TQWN STATE
<br />ZEP CtIDE
<br />"'
<br />C
<br />...:
<br />23a. DATE OF D1ATH (Mo., Day, Yr.)
<br />24a. DAta SIGNED (Mo., Day, Yr.)
<br />iu 11
<br />24b. TIME OF DEATH
<br />;>
<br />N
<br />Februa 11, 2022
<br />S $
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />1 24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24d. TIME PRONOUNCED DEAD
<br />>
<br />$
<br />g1.
<br />2
<br />09:39 PMI'll
<br />tl Tplt)a baht Cf rlry:Aitowhdga, death ouurred N the tune, date and place
<br />9
<br />ul 24e. OtI the baste of examination antlfor Imrestipation, im tlry oPlnbm tleapt elCgtu'red4a
<br />1.u41A.
<br />s
<br />atilt q lathe cijuse(s) stated. (Signature and Title)
<br />$ p . the time, Aate and place and due to the causes) stated. Intimation azul Title)
<br />~ .S
<br />I
<br />O.
<br />Jennifer L: Brown, MD
<br />26. DID TOBACCQ USE CQNTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BE1.EN CO,NSIDERED? 26b. WAS CONSENT GRANTED?
<br />YES NO LY ❑, UNKNOWN ❑ YES NO Not Applicable If 2$&I NO YRS No:::.
<br />0
<br />"""""""
<br />7 L :; N ER 1 I R (Type or Print)I'l1.
<br />.,
<br />Jennifer L. Srouvn„MD, 729 North Custer Avenue, Grand Island, Nebraska, 688fS3
<br />28a. REGISTRARS SIGNATURE
<br />��'��
<br />28b. DATE FILED BY REGISTRAR (Mo., ay, Yr.)
<br />I
<br />I—&_
<br />.
<br />February t 8, 2022
<br />�aJ
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