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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH.AND H AND g�lr�zwqi 5
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE' COPY OF THE ORIGINAL R ,0OO,FtD �C�AI �rT,H
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL, STATISTICS JO ;
<br />THE L EGAL DEPOSITORY FOR VITAL RECORDS: =
<br />DATE OF ISSUANCE
<br />AAILEYS_CC? R�
<br />9/.17/2003 200508536
<br />. ASSISTANT s L +
<br />LINCOLN, NEBRASKA - HEALTHANDHLMAi�F,filiVltr,;�SAa
<br />- r
<br />STATE OF NEBRASKA- DEPARTMENT OF iiEALTH AND HUMAN $Et��IGFi FIl IATT aA1aRT
<br />VITAL STATISTICS O
<br />CERTIFICATE nF T)FATH 4
<br />4. DECEDENT • NAME FIRST MIDDLE LAST
<br />2. SEX..
<br />3:. DAYEOF DEATH `. lMonin Day, Year]
<br />Robert Eugene 'Smith
<br />Male
<br />September 3, 2003
<br />4, CITY AND STATE OF BIRTH Mnot in U,S.A.. name country)
<br />5a. AGE - 4ast Birthday
<br />UNDER 1 YEAR
<br />UNDER !'DAY
<br />16. DATE OF BIRTH /Month. Day. Year) '
<br />5b, MOS, DAYS
<br />Se. HOURS' MINS.
<br />Ord Nebraska
<br />(Yrs.l
<br />nterval between onset and dealt,
<br />49
<br />Lp EE qq' gg
<br />26f. office bu�ding eIRY /SFec �1 , farmctory
<br />OF
<br />May 22, 1954
<br />7. SOCIAL SECURTIY NUMBER
<br />Sa, PLACE OF DEATH
<br />507-74-5339
<br />HOSPI_TAL:; Inpatient OTHER_: Nursing Mama
<br />ER Outpatient Residence
<br />86. FACILITY - Name tit normstitution, give street and number)
<br />Saint Francis Medical Center
<br />DOA � Other /specify
<br />8C. CITY. TOWN OR LOCATION OF DEATH
<br />8p, INSIDE CITY. LIMITS.
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes No ❑
<br />Hall
<br />ga. RESIDENCE - STATE 9b. COUNTY
<br />oo, CITY. TOWN OR LOCATION ..
<br />go. STREET AND NUMBER /rnc/uding Zip Cad ®)
<br />'
<br />Nebraska Hall
<br />Grand Island
<br />4046 Edna Dr. 68803
<br />--�
<br />10. RACE - ,e.g., White, Black. American Indian.
<br />1.1. ANCESTRY le.g.. Italian, Mexican,. Berman, etc,
<br />12, FX" MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE -tif wife. give maiden name)
<br />n n
<br />...(specify)
<br />American
<br />R DIVORCED
<br />,April Salmon.
<br />14d. USUAL OCCUPATION /Give kind of work dope during most
<br />146. KIND OF k1U$INE5S INDUSTRY,
<br />tN
<br />16. E DUCATION (Spacily only Highest rada completed)
<br />ot working life, oven if retired! -- - -
<br />Warehouse SupervlsOr
<br />p.qd Servic
<br />Hlgmgntary or Secondary 10.121 College 11 -4 or 5.1
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST " MIDDLE MAIDEN SURNAME
<br />M CAI
<br />Delpha Williams
<br />1Q. WAS DECEASED
<br />EVER IN US, ARMED FORCES? �]�
<br />C
<br />(Pas. no. or unk.)
<br />N�
<br />Yes
<br />I June 26, 1973 Jame 24 1977
<br />April Smith
<br />1 Pb. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />(7
<br />2Q. 84MER - ATURE & N$E N0.
<br />21 a. METHOD .OF DISPOBIYION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />#1071
<br />raw
<br />6, 2003
<br />_
<br />' FNNER H - N E
<br />21d -CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />❑ Cremation ❑ Donation
<br />North Loup, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R,F.D. NO.. CITY OR TOWN.
<br />59 1
<br />C
<br />I i
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<br />CD
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<br />G?
<br />W.10 -If
<br />�-
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH.AND H AND g�lr�zwqi 5
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE' COPY OF THE ORIGINAL R ,0OO,FtD �C�AI �rT,H
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL, STATISTICS JO ;
<br />THE L EGAL DEPOSITORY FOR VITAL RECORDS: =
<br />DATE OF ISSUANCE
<br />AAILEYS_CC? R�
<br />9/.17/2003 200508536
<br />. ASSISTANT s L +
<br />LINCOLN, NEBRASKA - HEALTHANDHLMAi�F,filiVltr,;�SAa
<br />- r
<br />STATE OF NEBRASKA- DEPARTMENT OF iiEALTH AND HUMAN $Et��IGFi FIl IATT aA1aRT
<br />VITAL STATISTICS O
<br />CERTIFICATE nF T)FATH 4
<br />4. DECEDENT • NAME FIRST MIDDLE LAST
<br />2. SEX..
<br />3:. DAYEOF DEATH `. lMonin Day, Year]
<br />Robert Eugene 'Smith
<br />Male
<br />September 3, 2003
<br />4, CITY AND STATE OF BIRTH Mnot in U,S.A.. name country)
<br />5a. AGE - 4ast Birthday
<br />UNDER 1 YEAR
<br />UNDER !'DAY
<br />16. DATE OF BIRTH /Month. Day. Year) '
<br />5b, MOS, DAYS
<br />Se. HOURS' MINS.
<br />Ord Nebraska
<br />(Yrs.l
<br />nterval between onset and dealt,
<br />49
<br />Lp EE qq' gg
<br />26f. office bu�ding eIRY /SFec �1 , farmctory
<br />OF
<br />May 22, 1954
<br />7. SOCIAL SECURTIY NUMBER
<br />Sa, PLACE OF DEATH
<br />507-74-5339
<br />HOSPI_TAL:; Inpatient OTHER_: Nursing Mama
<br />ER Outpatient Residence
<br />86. FACILITY - Name tit normstitution, give street and number)
<br />Saint Francis Medical Center
<br />DOA � Other /specify
<br />8C. CITY. TOWN OR LOCATION OF DEATH
<br />8p, INSIDE CITY. LIMITS.
<br />8e. COUNTY OF DEATH
<br />Grand Island
<br />Yes No ❑
<br />Hall
<br />ga. RESIDENCE - STATE 9b. COUNTY
<br />oo, CITY. TOWN OR LOCATION ..
<br />go. STREET AND NUMBER /rnc/uding Zip Cad ®)
<br />4e INSIDE CITY LIMITS
<br />Nebraska Hall
<br />Grand Island
<br />4046 Edna Dr. 68803
<br />Yes © No ❑
<br />10. RACE - ,e.g., White, Black. American Indian.
<br />1.1. ANCESTRY le.g.. Italian, Mexican,. Berman, etc,
<br />12, FX" MARRIED ❑ WIDOWED
<br />13 NAME OF SPOUSE -tif wife. give maiden name)
<br />atc,l(Specify)
<br />White
<br />...(specify)
<br />American
<br />R DIVORCED
<br />,April Salmon.
<br />14d. USUAL OCCUPATION /Give kind of work dope during most
<br />146. KIND OF k1U$INE5S INDUSTRY,
<br />tN
<br />16. E DUCATION (Spacily only Highest rada completed)
<br />ot working life, oven if retired! -- - -
<br />Warehouse SupervlsOr
<br />p.qd Servic
<br />Hlgmgntary or Secondary 10.121 College 11 -4 or 5.1
<br />12
<br />16. FATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST " MIDDLE MAIDEN SURNAME
<br />Alvin Arthur Smith
<br />Delpha Williams
<br />1Q. WAS DECEASED
<br />EVER IN US, ARMED FORCES? �]�
<br />19a, INFORMANT•NAME
<br />(Pas. no. or unk.)
<br />(It yes. give -or and dates of servic)(AO n
<br />Yes
<br />I June 26, 1973 Jame 24 1977
<br />April Smith
<br />1 Pb. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP)
<br />4046 Edna Dr., Grand Island,: Nebraska 68803
<br />2Q. 84MER - ATURE & N$E N0.
<br />21 a. METHOD .OF DISPOBIYION
<br />21b. DATE 21c.
<br />CEMETERY OR CREMATORY NAME
<br />#1071
<br />Burial El Removal
<br />6, 2003
<br />Hillside Cemetery
<br />' FNNER H - N E
<br />21d -CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />All Faiths Funeral Home
<br />❑ Cremation ❑ Donation
<br />North Loup, Nebraska
<br />22b. FUNERAL HOME ADDRESS (STREET OR R,F.D. NO.. CITY OR TOWN.
<br />STATE ZIP)
<br />j
<br />28a.
<br />2929. S. Locust St.,
<br />Grand Island,, Nebraska 68801
<br />6d. DESCRIBE HOW INJURY OCCURRED
<br />,dM IATE CAUSE
<br />PART
<br />(ENTER ONLY ONE CAUSE PER LINE FOR is), (b). AND (ell
<br />^
<br />I Interval between tinsel and death
<br />�y:
<br />_
<br />r
<br />5uielda Pendi ng
<br />UU 0 pR A GCN5E0 CE OF
<br />nterval between onset and dealt,
<br />eA
<br />Lp EE qq' gg
<br />26f. office bu�ding eIRY /SFec �1 , farmctory
<br />OF
<br />-
<br />I Interval between onset and tloam
<br />Yes ❑ No ❑
<br />Ipl
<br />-
<br />I
<br />�•
<br />PART OTHER SIGNIFICANT CONDITIONS Conditions contributing to the death but not related
<br />.PART III IF FEMALE, WAS THERE A
<br />24 AUTOPSY
<br />I
<br />26. WAS CASF. REFERRED TO MEDICAL
<br />rw
<br />27b. DATE SIGNED /MO.. Yr.) 27c. TIME OF DEATH
<br />a
<br />rber
<br />II
<br />M
<br />28c, PRONOUNCED DEAD (Mo.. Day, Yr.) 28d. PRONOUNCED DEAD (Hour)
<br />PREGNANCY IN THE PAST 3 MONTHS?
<br />rn
<br />See 1, 2013 7:54 a• M
<br />EXAMINER OR CORONER?
<br />$ 27d. TO the best of m owlep e, de h occurr d a the Ime, dot and la a and duo 16 he
<br />9 1 p c I
<br />ceuse(sl Staled. e , 9 X
<br />ffi
<br />286, On the basis of examination and, or investigation, in my opinion death occurred at
<br />(Ages 10-54) Yes No
<br />Y.S Nd X
<br />y
<br />YBa No q
<br />28a.
<br />26b. DATE OF INJURY /Ma.. Day. Yr,)
<br />26c. HOUR OF INJURY
<br />6d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Ondelermmed
<br />jtre.t
<br />5uielda Pendi ng
<br />28e. INJURY AT WORK
<br />Lp EE qq' gg
<br />26f. office bu�ding eIRY /SFec �1 , farmctory
<br />26g. LOCATION STREET OR R.F.D. N0: CITY OR TOWN STATE
<br />Homlclde Investigation
<br />Yes ❑ No ❑
<br />-
<br />27a. DATE OF DEATH (Mo.. Day. Yr.)
<br />28a. DATE SIGNED (Md.. Day.'Yr.) 286 TIME OF DEATH
<br />September 3, 2003 F�
<br />rw
<br />27b. DATE SIGNED /MO.. Yr.) 27c. TIME OF DEATH
<br />a
<br />rber
<br />i
<br />M
<br />28c, PRONOUNCED DEAD (Mo.. Day, Yr.) 28d. PRONOUNCED DEAD (Hour)
<br />rn
<br />See 1, 2013 7:54 a• M
<br />M
<br />$ 27d. TO the best of m owlep e, de h occurr d a the Ime, dot and la a and duo 16 he
<br />9 1 p c I
<br />ceuse(sl Staled. e , 9 X
<br />ffi
<br />286, On the basis of examination and, or investigation, in my opinion death occurred at
<br />�.
<br />/� /Gjw''
<br />the lime, data and place and due to Iha,dause(s) Staled.
<br />Si natureantl Tille ll•//JL•'�+ -- L(✓
<br />29. DID TOBACCO USE CONTRIBUX TO TiJE DEATH? 3 HAS ORGAN OR TISSUE DONATION
<br />$i nature and Title
<br />CONSIDERED? 30.b WAS CONSENT GRANTED?
<br />YES NO [] UNKNOWN © YES
<br />WN,
<br />� Y ES NO
<br />'31, NAME qND ADDRESS0 TIFIER (PHYSICIAN, CORONER'S PHV$ICIAN O -COUNTY ATTORNEY) (Type orP /
<br />John A. Wagoner M.D., 800 A7 a St. Gran
<br />Island Nebraska 68803
<br />32e: REGISTRAR
<br />326 DATE FILED By REGISTRAR tMd. Day, Yr,)
<br />JX
<br />
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