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<br />STATE OF NEBRASKA <br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALU:/ARURliM.4N SERVICES <br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE OR/~~tft;fi!#fILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL s1!ffJ$ff~!!i.~~W#ICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ;;~lf.~.'~..-.?\'".~..':.'.-:- f. .'~.~..,.'_CC..:~.'~'.'.~:l..."+..' <br /> <br />DATE OF ISSUANCE :.:: ~. .~:: .;tI~ll.i~" ;.: <br />Ie:" ',,'" . " "lftJJ#f'Sf:t:;OPPER <br />JUll 4 2006 2006065 4 5 '-A$SfSTAJ(P'STA~lJEQlgTRAR <br />LINCOLN, NEBRASKA H'EALTH-AWQiiNSfi!vICES <br />.:~:,. ",. ....'~.~.~','_. ~"-~: ..- ,. <br /> <br />DECEDENT - NNtoIf <br /> <br />flliS <br /> <br />STATE OF NEBRASKA-DEPARTMENT OF HEALTH <br />BUREAU OF VITAl. STATlSTICS_ _ ... <br />CERTIFICATE OF DEATH~) :J .:\U <br />MIDDLE <br /> <br />86 06997 <br /> <br /> <br />1411. Wood River <br />RESIDENCE-STATE COUNTY <br /> <br />I.... <br /> <br /> <br /> <br />Hall <br /> <br />12th <br /> <br />INSIDE CITY LIMITS <br />(Spo.Ifr.I.. 0' No) <br />1'0. Yes <br />-uu-- <br /> <br />Thompson <br />ISTNifT O. U.D. NO.. CITY O. TOWN. STATE. ll'l <br /> <br />MIDDL <br /> <br />MID <br /> <br />Smith 17. Etta <br />INfOll/lllANT - N.uAE - IElA trONSH" - MAILING ADDRESS <br /> <br /> <br />Jon Rath, <br /> <br />.lice Smith-Wife-305 W. 12th-Wood River, NE. 68883 <br />CEMETEIY 01 CIf_TOIY NAME LOCATION CITYQRTOWM STATE <br /> <br />2110:. Lincoln Memorial Cremator 20c1. Lincoln, NE. <br />I.S fUNEIlAL HOME NNtoIE AND ADOlfESS (SUE" O. U.D. NO.. CITY O. TOWN. STATl. 1"1 <br /> <br />22^pfel Funeral Home-Box i21-Wood River, NE. 68883 <br />. DA E SIG (Mo. 0'. Yr.) HOUI Of 0 A H <br />!'U J o.?O <br />lli- 2..... un.... - , 12: 30 <br />HOUIOf DEATH ..~~ ' PRONOUNClD DlAO <br /> <br />104 !~ii ~MO:~Ut{~ 20, 1986 4 . 1: 07 <br /> <br />J I~ . 0IIt ... ...., of ....mi...tiM fjlnd/tlr iftVftti,C11 1ft ..y opj"i.n ..... oc <br />:. U .. ri_t ... a.... pi..::. ..... ..... .. th. cO .fafecl. <br />. ' -- <br />U , 240. (Sill"""" ao" rill.) ~ ~ "'7 . <br />NErs 'HYSICIAN 01 COUNTY AnOINEl') (T,,.o or 'rin'} <br /> <br />County Sheriff, Grand Island, NE 68801 <br />DATE IKE'VED IV IE 'STRAI (Mo.. Dov. Yr.) <br /> <br /> <br />~ <br />"':5 <br />D~ <br />Afa <br />~I <br />.... <br /> <br />:~. <br />DATI! , NED (Mo.. Do,. Yr.) <br /> <br />1"G1STlAI <br /> <br />26o.(Si ........J.. <br />27. lMAilEDI.... AU <br />/ P~ Cardiac Arrest <br />(0' <br />DUI! TO, 01 AS A CONSlIQUEN(1! Of, <br /> <br />2610. <br /> <br />JUN 2 4 1986 <br /> <br />L1Nf 1'0' (II}, (b), AND (d) <br /> <br />'n..two' b......... Oft... and death <br /> <br />Unknown <br /> <br />1""......1 .,...... 0lIl'" .Ad d~1tt <br /> <br />,.., <br />OUI! TO, QIl AS A CONSEQUENCE Of, <br /> <br />t,.'*twal befweeft ..... IIIUlid d..th <br /> <br />lei <br />PAil I SIGNifICANT CON <br />IICancer of abdomen and liver <br /> <br />ACCIDENt. SUICIDE. MOMIClDE. UNDIT~ DATl Of INJUIIT (-. ....F. .".) <br />01 "NDlNO INYlsnGATION. (S_i"J <br /> <br />3Oa. <br />INJUIIT AT W~ <br />(S_lfr Yoo or No) <br /> <br /> <br />:::.1~;~J* r~~ J~~fM5t ts~~:L '" ,.,.) <br /> <br />1'0.0 No Ci 21. No <br />DESC.'IIIOW INJUIIT occu",_o <br /> <br />wAS CASE u'n.ID ro MEDICAL <br />!lIAMINE. 01 COIIONU <br />(S_.".,.. or ~e s <br />~,. <br /> <br />SOd. <br /> <br />~ <br /> <br />STun OI..'.D. Mo. <br /> <br />CITY 01 TOWN STAll <br />