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<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 OFISSt,JANCE`
<br />7/12/2018
<br />LIIVCOI lV, NEBRASKA
<br />I
<br />A
<br />0 aG- V'1 1 /G 0 INTERIMT OF HEALL LTSTATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES •
<br />STATE OF NEBRASKA - DEPARTNIENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE t F DEATH''
<br />1. DECEDENT$ -NAME •(First, Middle, Last, Suffix)
<br />Susan Marlene Smith
<br />4 CITY A $D STATE OR I DE.RITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Holdrepe,• 8Mbra
<br />7. SOCIAL SECURITY NUMBER
<br />,505-78-903:7
<br />Ifs AGE Last l 1thday
<br />82
<br />4a.t D R.1YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient OTHER, 0 Nursing HomeA.TC
<br />ER/OUtpatient 0 Decedent's Home
<br />0 DOA 0 Oth.r (Specify)
<br />8b FACILITY-i1IA1iIE (If tl01..I titution, give strait and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />fin RE81DENCE S1.ATi
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1004 West 7th Street..
<br />. COUNTY
<br />Hall
<br />DAYS
<br />HOUR
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Y, )
<br />June 30, 2018
<br />8. DATE OP ECM .(910.; D
<br />October 16, 19 55
<br />8d. COUNTY OF DEATH
<br />Hall
<br />'# : OR TOWN
<br />Grandlsland
<br />IN. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />90 INSIDE CITY:UMrTS"
<br />® YES ❑ NO
<br />10a. MARITAL S, TATUS ATTIME OF DEATH ® Married 0 Never Married
<br />© Married, but separated• 0 Widowed 0 Divorced 0 Unknown
<br />iDb.;NAMEOF.:SPOUSE,(Firat,... Middle, Last,
<br />Earl E .. Smith
<br />ffix) If wife, give maiden name
<br />.S
<br />C
<br />11. FATHER'S NAME (First, Middle, Last, Suffix)
<br />-;:Kenneth •;:•Asche
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Pearl Beyersdorf
<br />13. EVER IN U.S. ARMED FORCES
<br />(Yes Na. or Mt) NO
<br />Give dates of service if Yes.
<br />14a. INFORMANT -NAME:...
<br />Earl E Snaith
<br />14b. RELATIOI!ISNIP;TO DECEDAetT;..
<br />Spouse
<br />18. METHOROt SPOSmT(ON
<br />®Burltll .. Donation
<br />❑ Cremation 0 Entombment •
<br />❑ Removal ❑ 0ttax-Specify)
<br />18a. EMBALMER -SIGNATURE
<br />Andrew D. Purcell
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Cemetery
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)'
<br />Apfei Funeral Home. 1123 W. 2nd. Grand Island. Nebraska
<br />1Ab. LICENSE NO.
<br />1486 •
<br />CITY !TOWN
<br />Grand Island
<br />tea DATE (Mo., Day, Yr.)
<br />July 6, 2016
<br />STATE
<br />Nebraska
<br />17tX Zip:code
<br />68801
<br />CAUSE OF DEATH I$ee IpstruciipnE.and examples)
<br />Mk PART I Enter the chain _-diseases, Injuries, or cemplicatlons4hat directly catMad tilt tl0 NOT enkytenMninityMns such as cardiac arrest,
<br />respiratory arrest] or ventripdar fibrillation without showing the etiology. DO NOT ABDO*RA*E. Eller onlytone.cause lint a **Add additional Ikea a necessary.
<br />IMMEDIATE CAUSE
<br />a) Unknown Natural Causes
<br />.IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />ip death}
<br />SequthdegylistcpntltMna,If
<br />any teadinp to the eauaa Verse
<br />Enter the UNDERLYING CAUSE
<br />;.Pseas. fk.:Oflgjury that InitiM4,d:�.
<br />the assets re$ulR ;in death) . :
<br />:usr>
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Cardiac Arrest
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Ventricular Fibrillation
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d).l Hypertension
<br />APPROXIMATE >iNTERVAL-
<br />onset to'deatll ..;:
<br />onset .':
<br />Midcalf
<br />onset to death
<br />30 Minutes
<br />1& PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART L
<br />Gorr plaided Ci interm ttent Chest Pains Last Several Months; Had Seen Primary: Care physician,...
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ Vas lid NO
<br />20IF°FEMALE i
<br />• ® Not pregnaitttwaMnpast' year •
<br />0 Pregnant at time of death
<br />❑Mat pregnant:bm
<br />.om0000t within 42 days of death
<br />Not pregnant, but pregnant.0 days tot year before death
<br />❑ UnentrwA It prn4ntict wtttili'ins. piest year •
<br />21a. MANNER OF 0TEATH
<br />® Natural 0 Hdnlcide
<br />o Accident 0 Pending investigation
<br />❑ Suicide ❑ Could ittt be detkdgined
<br />210F 1PANSPORTATION INJURY
<br />1 . Ifiiver/Operator
<br />❑ Passenger
<br />Qpedestrian
<br />Other'(Specifyl
<br />210. WAS AN AUTOPSYAERFFORMED7;
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE Dlt DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY No., Day, Yr.)
<br />92d..ENJUf Y AT WORKI :>!
<br />QY(~S ,❑NQ:
<br />22b. TIME OF INJURY
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO.
<br />ase DATE OF: DEATH (Mi
<br />Day, Yr.)
<br />2331 DATE MOWED (Mo., Day, Yr.)
<br />22c. PLACE OF INJURY -At home, faint, street, factory, office building, oonsbuodan site, etc. (Specify)
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />ad. To the beet of my knowledge, death occurred at the time, date and pace
<br />and due to the cause(a) slated. (signature and Title)
<br />IIID TQ A
<br />®`YES
<br />USE CONTRIBUTE TO THE DEATH?
<br />NO ❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />. ()4Th SIGNED (Mo., Day, Yr.)
<br />July 2 2018
<br />54c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />June 30, 2018
<br />1SP CODE
<br />24b. TIME OF
<br />11:34 AM
<br />24d. TIME PRONOUN.:::,:
<br />11:34 AM
<br />24e On the basis of exmdnaeon and/or (maoagation, In my aplakta death occurred at
<br />ate time, date and place and due to the cue (s) slated. (Signabxe and Titre)
<br />S. Alex West, Hall Deputy County Attorney
<br />26a. HAS ORGAN OR TISSUE<DONATION SEN'CONSIDERED?
<br />® YES ❑NO
<br />26b. was c NISLINT GRANTED? ;
<br />Not Applicable if 26a Is NO OYES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />S.. Alex West Hata.,Depldl County Attorney, 231 S. Locust,. Gr
<br />steak ISTR,e re SiONATEIRE
<br />nd`Island, Nebraska, 68801
<br />28b. DATE FILED BY REGI
<br />July 5, 2018
<br />1
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