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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON flLE WItH,"_
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTlON;:WHl.CHJs:._"~""c""
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~, .t _--~/J,-,,~ \~:,-iJ;v,-::'{ - -
<br />DA TE OF IssuANCE f4JJ ,-WV{Y
<br />2/14/2005 200606 31'3 ASSISTANT ::i;:E;:=~
<br />LINCOLN, NEBRASKA ,,_, HEA~ TH AND HUMAN SERvtCEpSrST~,
<br />STAlE OF NEBRASKA- DEPARTMENT OF HEALlH AND HUMAN SERVICES FlNANcE AlIDSUPPoR.T
<br />VITAL STATISnCS '; '0 A-. ,1 4 8 0 5
<br />CERTIFICATE OFDEAlH ~':I:<" ,.
<br />
<br />
<br />1. DECEDENT. NAME
<br />
<br />FIRST
<br />
<br />MIDDLE
<br />
<br />LAST
<br />
<br />Z, SEX
<br />
<br />3, DATE OF DEATIJ' '(Monlh. Day, Yeal/
<br />
<br />Paul
<br />4, CITY AND STATE OF BIRTH IUno/ln u.s.A. """'" aow/ry)
<br />
<br />Edward Smidt JR
<br />5._ AGE ",Coot EM_v UNDER 1 YEAR
<br />(y"'-I 5\>_ MaS. DAYS
<br />
<br />4~t
<br />
<br />I
<br />" I
<br />80, PLACE OF DEATH
<br />
<br />Male
<br />_UNDER I DAY
<br />5<, HOURS I MINS,
<br />I
<br />I
<br />
<br />Dee 22 2004
<br />6, DATE OF BIRTH IMonth, Day_ Y..r)
<br />
<br />~~;_~~~,"_~alifornia
<br />7_ SOCIAL SECURTIY NUI,16ER
<br />
<br />Oct 16 1964
<br />
<br />508-02-3652
<br />6b, FACILITY" Na"", (HnDlinstituOOrr, gi.. "'oeland n_i
<br />
<br />HOSPITAL:
<br />
<br />o Inpatient
<br />o ER,()utpAlient
<br />o DOA
<br />
<br />OTHER.
<br />
<br />D. NurSing HOme
<br />
<br />o Rel!l.idenee
<br />~ other (Spocllyl
<br />
<br />Business-F:t"orage
<br />u din
<br />
<br />2820 w. Old H 30
<br />
<br />~, AeSlOENCE~STATE
<br />
<br />
<br />
<br />""- STREET AND NUMBER (11l(;/V4/ng ~p ~i
<br />
<br />ge. INSIOe: CIty LIMITS
<br />
<br />ac. CITY. TOWN OR l.OCA nON OF OEA. TI-I
<br />
<br />lid, INSIDE CITY LIMITS
<br />
<br />Grand Island
<br />
<br />Nebraska Grand Island
<br />10_ RACE" lo-g" While, BI.ek_ Am.,.;ean Indl"", 11, ANCESTRY 10,9" ""liar, !loxieon. German, o'el 12_ l!1 MARRIED
<br />ele,lls"acilyl fS","eilyl
<br />White German/En lish/Danish NEVER
<br />1'._ USUAL OCCUPATION IGI..*lr>dot_I,,;loM<hJringmosJ 14b_ KIND OF'aUSINESS INDUSTRY
<br />01 "",.ing ff/Q, ._trelirodi '
<br />
<br />_nQwner/QpercttQr_ Lawn Care
<br />16_ FATHER" NAI,1E FIRST 1,110DlE LAST 17 MOTHER
<br />
<br />68803
<br />
<br />Yos~ No 0
<br />
<br />13_ NAME OF SPOUSE III Wile_ gi" maidOn name)
<br />
<br />Lois Schumm
<br />15, EDUCATION [S","eily only high'" grede eomple.od)
<br />EJemen'i or SeeondaJY (0-12) I College 11-4 or 5+)
<br />2 0
<br />MIDDLE MAIDEN SURNAME
<br />
<br />
<br />Paul
<br />
<br />Vir inia Lee Donner
<br />
<br />
<br />Island
<br />".)L~92
<br />
<br />NE 68801
<br />21 a METHOO OF OISPOsmDN ~1 b_ DATE
<br />
<br />~le, CEMETERY'OR CREMATORY. NA/,1E
<br />
<br />I!l 6uriel 0 Romoval Dee 27, 2004 Grand Island City
<br />21d. CEI,1ETERY OR CREMATORY LOCATION CITY OR 'TOWN
<br />
<br />STATE
<br />
<br />Curran Funeral Cha e1
<br />22h, FUNERAL HOME ADDRESS (STREET OR'A-ED: NO" CITY OR TOWN, STATE. ZlPI
<br />
<br />o Cremation 0 Dorallon
<br />
<br />3168 w. Stolle
<br />
<br />Park Rd. Grand Island NE
<br />
<br />3005 South Locust Street
<br />213, II.1MEDIATE CAUSE'
<br />," PART
<br />I
<br />
<br />Grand Island NE 68801
<br />(ENTER ONLY ONE CAUSE PER LINE FOR Is),lb). AND fell
<br />
<br />Interval between onse1 3t"1d oealh
<br />
<br />=
<br />
<br />I-I
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />Sharp
<br />
<br />force
<br />
<br />trauma
<br />
<br />to
<br />
<br />neck
<br />
<br />with
<br />
<br />exsan~uination
<br />
<br />3 min
<br />
<br />ii
<br />
<br />Intetval between OflSfJt and death
<br />
<br />Ihl
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />
<br />
<br />I Interval between onset and death
<br />I
<br />I
<br />I
<br />25, WAS CASE REFERRED TO MEDICAL
<br />EXAMINER OR CORONER?
<br />No
<br />
<br />(el
<br />OTHER SIGNIFICANT CONDITIONS -Conditions contributing 10 .ho _111 bul nat ,ol.ted
<br />PART
<br />II
<br />
<br />26e,
<br />
<br />Accident 0 Undetermin$d
<br />Suicide 0 Pending
<br />
<br />with
<br />
<br />a
<br />
<br />chainsaw
<br />
<br />26g, LOCA110N
<br />
<br />S'ffiEET OR A,F,Q, NO,
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />2820
<br />
<br />w
<br />
<br />Old
<br />
<br />H~I)Y
<br />
<br />30,Grand
<br />
<br />Island,
<br />
<br />NE
<br />
<br />2~, DATE SIGNED lMe" DOy- Yr.)
<br />
<br />~, TII,1E OF DEATH
<br />12:12am
<br />
<br />M
<br />
<br />27cl. 1'0 tne b9al 01 my )(t'loWladge, deatn oc:cl.JrrQd at the time, date and plaee and dU{I 10 the
<br />C8lJse(sl stated.
<br />
<br />
<br />%i:; Feb 8, 2005
<br />i i ! >- ~e_ PRONOUNCED DEAD lMe" D8y; Y'I
<br />8ffii~ Dec 22, 2004
<br />~ ~ ~ ~, On the basis at examination and'
<br />8 5 111. Iim.. dolo ard plaoo ,~.
<br />
<br />~r ~RONOUNCF.D DEAO lHoor)
<br />12:45 am
<br />
<br />M
<br />
<br />=l;:i
<br />
<br />-I"
<br />'"
<br />>->-
<br />- 0:"
<br />, 8f'o
<br />B
<br />,2
<br />
<br />2"', DATE SIGNEQ IM<1, O.y, YO
<br />
<br />27e, TIME OF DEATH
<br />
<br />M
<br />
<br />
<br />Atty
<br />
<br />NO
<br />
<br />NAME ANO ADDRESS OF CERTIFIER /PHYSICIAN, CORONER'S ~HYSIC1AN OR COUNTY ATTORNEYI fry"., or Print)
<br />
<br />Mark J
<br />
<br />Young, Hall
<br />
<br />~J.
<br />-------g.---
<br />
<br />
<br />Attorney,
<br />
<br />231 S
<br />
<br />Locust, Grand Island,
<br />
<br />3~, DATE FllED;c rEfl tr2fids
<br />I
<br />
<br />NE
<br />
<br />68801
<br />
<br />32.. REGISTRAR
<br />
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