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BE
<br />HUMAN
<br />STATE OF NEBRASKA
<br />I,/tII��I��11A."?;;.; `M.'/, /Inrn„1\'^::; ••.;, �0 IIn111 ��.:"""i r' Ir . 11 1`a;;.;..:1tfrt u. ly?dl�llldyl� !'))! rigs ��UY'r/24gi 111111 �.
<br />*<6.641/ilY,1.1N@F:.-.-;�: -- rrrn .<Y.d(t�.1,/1.�11go�. •'.:° e'ehuu..�1�<. <..�
<br />COY 0 RR I S THE RAISED SEAL OF STATE OF NEBRASKA, IT'CERTIFIES THE DOCUMENT BELOW TO
<br />:copy.0:FtelE ORIGINAL RECORD ON FILE WITH `THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />iVI ESr VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATE; OP IS$U AN E
<br />i1 W2c22
<br />LIN'COLN, NEBRA$KA.;
<br />202600865
<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 />; .REC A!?NTS$Al E'Fi•
<br />aro.: >:+
<br />liddle, Last, Suffix)
<br />2 1250
<br />2. SEX
<br />Female
<br />3. DATE OF D 4 E ft,(Adi .. pay;'
<br />4. CITY..lF[!D S:A.r,r TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />ll,.SOLlth.:D kQta
<br />:.. AL S tlRI TY Ni/MaER
<br />4'
<br />5a. AGE - Lasf.•Birthday.
<br />(Yrs.)
<br />51
<br />IkJTY NAME'tift;ktstitltloit, give
<br />umber)
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />8a; PLACE OP DEATH
<br />OS#ITAL.:: ❑ inpatient
<br />0 ER/Outpatient
<br />❑ DOA
<br />DAYS
<br />HOURS
<br />MINS.
<br />8
<br />ctob>t;<:190
<br />OTHER ❑ Nursing Home/LTC
<br />IE Decedent's Horns
<br />❑ Other(Specify)
<br />=0
<br />riillf(r(
<br />H1,,6i
<br />EA:. el ZIP Code)
<br />8d. COUNTYOFDEATH
<br />Hall
<br />TA
<br />Nibrask
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand. Island
<br />�ET:AeIEN
<br />515>f an lb1dsAVt3.
<br />' ARITAL
<br />P
<br />AT (ME
<br />DEATH ® Married 0 Never Married
<br />d ❑ Divorced ❑ Unknown
<br />Be. APT. NO.
<br />W. ZIP CO
<br />68803
<br />111b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, glv
<br />Gene Smith
<br />AT.8
<br />ri
<br />Ie, Last, Suffix)
<br />12.:MOTHER'S-NAME (First, Middle, Maiden Supii
<br />Connie:;. Lucille Allen
<br />EEVER IN U{*1••• N:,g
<br />0
<br />dates of service if Yes.
<br />14a. INFORMANT -NAM
<br />Gene Smith
<br />8a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1Ed CEMETERY, CREMATORY OR OTHER LOCATION'
<br />Central Nebraska Cremation Services
<br />AND MA) ING ADDRESS (Street, City or Town, State)
<br />lie, 2929'S. Locust Street, Grand Island, Nebraska
<br />18b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH` (See instrudtIOns;and examples)
<br />esus, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />fatten without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines B necessary.
<br />IMMEDIATE CAUSE:
<br />ittttlple Sclerosis
<br />rguemeay tat=dnr+ditio(fs.`it'
<br />1ya 0✓A1tlt+a'iha..aW.!1:1>Ft!d
<br />t,ttii
<br />ite04004 E1(SING:;0i(ta '8
<br />kteii#a;9i'idJt+F��s liiitii't
<br />OR AS A CONSEQUENCE OF:
<br />Du TO, OR AS A CONSEQUENCE OF:
<br />'t'tol::pf NYAti`litjl tpgtt td wliriltt 42
<br />Nat.pragaant, b{dt pragd+aritsa'gays
<br />unxnown it:b r Qua twit in ittaeast
<br />0, OR AS A CONSEQUENCE OF:
<br />NDiii0NS-Conditions contributing to the death but notresu
<br />21e. MANNER OF. DEATH
<br />Natural HgmitOds
<br />❑ Accident ❑ Panning Invdiatigatlon
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />BE HOW INJURY OCCURRED
<br />NUMBER, APT.NO. CITY/TOWN:
<br />'D EATH (Mo., Day, Yr.)
<br />I1t C, i, 2022...
<br />E(2i1J1 b(MQr Day, Yr.) 23c. TIME OF DEATH
<br />2Q ; 07:00 AM
<br />t , death occurred at the time, date and place
<br />4 i s fi4Sss(al et.ed: {Signature and Title)
<br />g In the Underlying cause given in PART I
<br />21b.::IF.TRANSPORTATION INJURY
<br />Drier/Operator
<br />❑ Reminder
<br />Pedestrian
<br />❑ Other 18pecify)
<br />14b, RELtiTIONS3li9 !ODEC
<br />2tS AV
<br />TOCOMPI,E C1 EGE.E ATW
<br />Q YES :'. ❑::Nfi3'
<br />m, street, fattory, office building, con
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24b, TIME OF DEAT
<br />24d. TIME PRONOUNCE
<br />:toe. Oh:the;bails of examination and/or investiDatlon, In my ophtitid. tfS:oCeu#h
<br />the said, date and place and due to the causes) stated. (8ipiteturs a11t!>.'f`S.iEs!
<br />�¢ F1krS (t liTHE DEATH? 28a. HAS ORGAN OR TISSUBDONATION BEEN CONSIDERED?
<br />'PROBABLY 0 UNKNOWN 0 YES e
<br />2( HAMi #t 'I N 3 AOO ESS OF CERTIFIER (Type or Print
<br />at}t Sett] ' D- 211.B V.lt Faidley #400, Box 9802, Grand Island, Nebraska, 88803
<br />26b. WAS CONSENT GRANT
<br />Not Applicable if 28a is 'ElNO .'i S .; :❑ ftf0:
<br />28b. DATE FILED BY REGISTRAR (Mo„ Day, Yr.
<br />September 14, 2022
<br />
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