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<br /> WFEN TFpS COPY CARItE3 TFE RA13ED SFAL OF THE II�BRASKA HEALTH AND HH,�RINCES C\ �
<br /> SYSTF_A�,IT CERTF�S THE BELOW TO BE A TRUE COPY OF THE OR/OINAL/t�C--��p�i �v �
<br /> THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM,VITAL STATISTI�`�'j��iF�.- c`�
<br /> THE LEOAL DEPOSITORYFOR VITAL RECORD� _- - - � '� -=`
<br /> DATE OF ISSUANCE == ��"'- �
<br /> �h�'= - __
<br /> �/�����AAI�� :-
<br /> SEP 141999 �� 10 9 3 0� __ _ -�� _.
<br /> Assrs�3r�re�a�srr� �
<br /> UNCOLN,NEBRASKA HEALTHAND HUIf�N -
<br /> �g�=
<br /> S'tATE OF NEBRASKA-DEPARTMENf OF HEALIN AND HUMAN SERVIG'F��I�bbCE AND SdtPPORT
<br /> V1TAL STATISTICS =- =
<br /> CERTIFICATE OF DEATH
<br /> t.DECEDENT-NAME FIRST MIDDLE LAST 2.SE% 3.DATE OF DEATM /MOnlh.Day Year/
<br /> John Joseph Smith Male August 8, 1999
<br /><.CITV AND S7ATE OF BIR7H /Mnpf ir U SA.,nams eoun6yJ Sa.AGE-lasl&rthdey UNDER i VEAR UNDEF t DAV 6.DATE OF BIR7H /MOn(h.Day YearJ
<br /> (Vra.l Sb.MOS. I DAYS Sc.HOURS' MINS. �n�o �
<br /> Parsons, Kansas 70 November 7, � o �,
<br />).SQCIAL SECURTIV NUMBER 8a.PLACE OF DEATH C7
<br /> 511-22-5673 HOSPITAI � �npatieM OTHER: � Nurslrg Home
<br /> Bp.FACIUTV-NarM /Mnol insN'luhbn,BiVe SbBII a�d numbN/ -�-�- � ER pulpe�ieM � ReSWence t�
<br /> St. Francis Medical Center ❑ �^ ❑ a�����ry� g
<br />&.CITV.TOWN OR LOCATION OF DEATN 9d.INSIDE CITV UMITS 8e.CWNTV OF DEATM �
<br /> Grand Island �« � �,❑ Hall �
<br /> 9a.REStDENCE-STATE 9b WUNTV 9c.,CITV.TOWN OR LOCATION 9d.S7REET AND NUMBER /lnc/udirgZrp Codel � 9e INSIDE CITV LIMI75 ., _ r
<br /> 7�� ii ^ pV (\
<br /> 10.NA�C�Lj^e.g�.,Whni1 Blatk.American hCian. r11a,ANCESTRV 1e.9..���xican�G�„nd Island�MARRIED O W�W�X'139��10 W��.���n name/� No� �
<br /> etallSOec�y� r,�lte ISWa1y1 NEVER DIVORCEO �
<br /> YY11 American Alma M. Ri er
<br />�aa.USUAL OCCUPATION lGive kinOd wak dm�olnhp mnal 11G.KIND OF BUSINESS 1NOUSTRV 15.EDUCATION (Spscily only hphaet qnAa complsleE�
<br /> d�.wkxg lils,swn il nfirsdl ENmenu a Sscondsry 10•t 2� Cdbqe It-a or 5-i
<br /> Machinist Union Pacific Railroad �2
<br /> 16 FaTHEF•NAME FIRST MIppLE LAST �7 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br /> Ferdie Smith Alice Musgrove �.
<br /> iB.WAS DECEASEO EVERIN LLS.ARMEO FOqCES4 198.INFORMANT-NAME -
<br /> �Yes��u�i�o ean9��War�8�2N46� 2-4-54 Alma Smith
<br /> i 9p INFORMANT MAILING ADDRESS ISTREET OR R.F.D.NO..CRY OR TpWN.STATE.ZIP�
<br /> P.O. Box 1392, 818 W. lst, Grand Island, Nebraska 68801
<br /> 2p.E ALMER-SIGNATURE 8 L ENSE 2ta.METMOpOF qSPOSiTiON 21b.DATE 21c CEMETERV OH CREMATORV�NAME �
<br /> /z3(o �a��.� �Rertwval Au . 11, 1999 Westlawn Memorial Park A
<br /> FUNERAL HOME-N E • 2ttl CEMETERV OR CREMATORV LOCATION CITV OR TOWN STATE �w
<br /> Apfel-Butler-Geddes �CnmWbn ❑�,���o� Grand Island, Nebraska� �
<br /> 22G.FUNERAL HOME ADDRESS ISTREET Op RF.D.NO..CITV OR TOWN.STATE,ZIP� � 4 �
<br /> N
<br /> 1123 West Second, Grand Island, Nebraska 68801-5899 U`�
<br /> 23. IMMEDIATE CAUSE �ENTER ONLY ONE CAUSE PER LINE FOR�al.Ibl.ANO(cll I Intervai between onset antl tleam 1
<br /> PAqT r �
<br /> ' A,'��t� ���n�rcu,�i r �jr,'��q�i ,� � /�p���s
<br /> Iai
<br /> DUE TO.OR AS A CONSEOUENCE OF: I �rval Oetween onset antl tleatn
<br /> • . ♦ I
<br /> �b� (,LJ�_�"Wi �/ +��G�Li 1�S/f�rDl.` ��71�.�
<br /> DUE TO.OFi AS F GONS� ENCE OF� i Irnerva�Eenveen e�a�an deam
<br /> i
<br /> I�I �
<br /> I
<br /> OTHER SIGNIFICANT CONDITIONS-ConOitions coMribtirq tp Me Ceatn bu1 rqt related PAR7 III IF FEMALE.WAS THERE A 2a AUTOPSY 25.WAS CASE HEFERRED TO MEDICAL
<br /> P�RT � PREGNANCV IN THE PAST 3 MONTHS7 EXAMINER OR CORONER�
<br /> 11
<br /> IAges t0-Sa� Ves No Yes Na Ves No
<br />'�� 26b.DATE OF INJURV /MO..Oey.YcJ 26t.MOUR OF INJURY 26d.DESCRIBE HOW INJURV pCCURRED
<br />] AccMeM � UntlMxmirieG
<br /> M t
<br />� Su�cWe � Pendvg 28e.INJURV AT WORK 26i.PU�CE OFi��V�At fa,qq,fa�m.stree�.tactory 26g.LOCATION STREET OR q.F.D.NO. pTV OR TOWN ` JS7ATE
<br />� O ❑ olfi Wild Spetnl'I
<br /> Haniclde investlga�ron ves No
<br /> 27a.DATE OF DEATH /Mp..Day Yc/ 28a.DATE S�GNED /Mo.Day Ycl 286.TIME OF DEATH
<br />�= August 8, 1999 <>
<br /> b�Q �,1
<br />��`�s 27D.DATE SIGNED /Mo..Day Yc/ 27a TIME OF DEATH < 28c.PRONOUNCED DEAD lMO..Day.Ycl 28d.PRONWNCED DEAD lFburl
<br /> � �
<br /> B August 13 , 1999 12 : 02aM �W�� M
<br />'q 270.To the heat ol my knovAetlqe. xcurrW IM time,Aab antl pace and Eue to tha ��� 28e.On the baais of examination antl�a imrestigation,in my oqnion tlealh occurred at
<br /> caux�s�eu�etl. � a
<br /> the ume.Cate and pace and due to Me eause�s)sW�etl.
<br /> (Si naWro aM Tilb Si nalure anO Tide
<br /> 5 DID TOBACCO USE CONTRIBU E TO TME DEATH7 3Qi MAS OROAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br /> � VES NO� UNKNOWN �J� VES � NO � VES NO
<br /> %"� T-
<br /> Il.NAME ANO ADDRESS OF CERTIFIFA IPHVSIGAN,COqONER'S PHYSICIAN OR CWNTY ATTORNEYI ITyps pPriMl
<br /> Thomas F. Werner M.D. �2444 W. F�id�,ey Ave. , Grand Island, NE. 68803
<br /> l28.REGISTRAR _ aM, n�rc cu m nv ocnicro�o iu, n..,v.�
<br />
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