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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HumANZikaityttirggitinas
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<br />THE BELOW TO BE A TRUE HUMAN SERVICES, VITAL RECORDS ORECORDPY OF THE ORIGINAL Afr OF HEALTH AND
<br />ORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY Mir
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<br />DATE OF ISSUANCE
<br />08/04/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMA
<br />CERTIFICATE OF DEATH
<br />To be completed/verified by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Alice Patricia Smollen
<br />2. SF4X �l J
<br />Fenlale ` '-
<br />3 jYE'O BATH (Mo., Day, Yr.)
<br />' July<2'3, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY'
<br />' 6TbATE OF BIRTH (Mo., Day, Yr.)
<br />Grand Island, Nebraska
<br />(Yrs.)
<br />77
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />August 2, 1937
<br />7. SOCIAL SECURITY NUMBER
<br />506-50-2079
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ® Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Wedgewood Care Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CIT/ OR TOWN OF DEATH (Include Zlp Code)
<br />Grand Island 68803
<br />3d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2310 Vandergrift Ave
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Frank Smollen
<br />11. FATHERS -NAME (First, Middle, Last, Suffix)
<br />Maurice Nealon
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Margaret Donnelly
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />Frank Smollen
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16b. LICENSE NO.
<br />1092
<br />16e. DATE (Mo., Day, Yr.)
<br />July 28, 2015
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />1
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER .......7
<br />18. 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, APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Tine. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Gastric Carcinoma(adenocarcinoma Of Stomach)
<br />disease er condition resulting
<br />onset to death
<br />1 Year
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Sequentially list conditions, If b) I
<br />any, leading to the cause listed I
<br />I
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Enter the UNDERLYING CAUSE C) i
<br />(disease or Injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: i Onset to death
<br />LAST d) I
<br />I
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART 1.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES ®NO
<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 />0Accident
<br />0 Suicide ❑Could not be determined
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. 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. CITY/TOWN STATE ZIP CODE
<br />-
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<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 23, 2015
<br />a
<br />Y a
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
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<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />July 27, 2015
<br />23c. TIME OF DEATH
<br />06:50 PM
<br />I1 G ,
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<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />e'E6i
<br />Q O
<br />oLia
<br />5
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cancels) stated. (Signatureend Tale)
<br />Steven Husen, MD
<br />° 1 a
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<br />24e. On the basis of examination and/or investigation, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and We)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES I NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR
<br />0 YES
<br />DONATION BEEN CONSIDERED?
<br />Igi NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable H 26a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Steven Husen, MD, 2116 W Faidley #400, Box
<br />9802, Grand Island, -•- ka, 68803
<br />P
<br />28a. REGISTRAR'S SIGNATURE 45
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 29, 2015
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