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<br />.. <br />"wHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA HEA[THANDHUMAN SERVICES <br />SYSTEM, "CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGIN4A.-RJ!67JRlJ.t1~ FILE WITH <br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VlTALSTA!f'/$T/(jg--8ECllON; 'WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. '~fiii1/;-;)-.J-=:~riJf,~ <br /> <br /> <br />D~i;/~~~;CE 20061 0 306 fr;:iiJ:rt&it~Jz: <br />LINCOLN, NEBRASKA HEALTH ~NiJ~!lU~~~~'r!~~~--!l~TEM <br /> <br />. - .. :.....-::-"""~~--..:. - . -'" ......:. - -~-==- <br />STAlE OF NEBRASKA- DEPARTMENT OF HEALlH AND HUMANSERVItES-FllllAHeE AiiD SUPPORT <br /> <br />CERTI;:~S;~~;~EAT~.~" "'~.:;; 0 3 <br /> <br />08748 <br /> <br />1. DECEDENT - NAME <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />2. SEX <br /> <br />:1 DATE OF DEATH (Month. Oav. Year) <br /> <br />Monica <br /> <br />Margaret <br /> <br />Smith <br /> <br />Female <br /> <br />July 31, 2003 <br />6. DATE DF BIRTH {Month. Oay. Yearl <br /> <br />4. CITY AND STATE OF BIRTH If{ nolin USA nome countryl <br /> <br />Cedar Rapids, Nebraska <br /> <br />5a. AGE. Last Birthday <br />{Yrs.1 87 <br /> <br />UNDER 1 YEAR <br />5b. MOS. I DA Y5 <br />I <br /> <br />UNDER 1 DAY <br />5e. HOURS MINS, <br /> <br />April 27, 1916 <br /> <br />~ 7. SOCIAL SeCURTIY NUMBER <br /> <br />St. <br /> <br />(If "ot JtIstiltJtH;:m. give streel and nI,.J'PPer) LT <br />.....enter- <br />Francis Memorial Health~ <br /> <br />a.. PLACE OF DEATH <br /> '!5'~PITAL 0 Inpatient OTHER: 00 Nursing Home <br /> 0 EA Outpatient 0 ResIdence <br /> 0 DOA 0 Other (S~".lfVJ <br /> <br />. <br />) <br />~ 8b <br />I <br />') <br /> <br />508-30-8076 <br /> <br />FACILITY - Name <br /> <br />MIDDLE <br /> <br /> <br />Hall <br />STREET AND NUMBER IlncfUding Zip C_I --- "90~ INsiOecITVliMii-S' <br /> <br />:: 8e. CITY. TOWN OR LOCATION OF DEATH <br /> <br />6d. INSIDE CITy LIMITS <br /> <br />COUNTY OF DEATH <br /> <br />Grand Island <br /> <br />Nebraska <br /> <br /> <br />11. ANCE.SfRY (e.g., Iti;llian, Mexican. German, elc:l <br />(Spaclfy) <br />German/Irish <br /> <br />14b KIND OF BUSINESS INDUSTRY <br /> <br />Alfred R. Smith <br /> <br />s.."ESlDENCE - STATE <br /> <br />Hall <br /> <br />Grand <br /> <br />14th 68801 Ye, [] No D <br /> <br />13, NAME OF SPOUSE (lfwlfe. giv8 maiden name} <br /> <br />10. RACE - (e.g., White. Black. American IMian. <br />etc.l (SPl:!CI~"'I"'i . <br />wnlte <br /> <br />14a. USUAL OCCUPA lION {Give kind of work done dutlng mosl <br />I of working /ils. e~ I~ retiredl <br />tiomemaker <br /> <br />Domestic <br /> <br />15. EDUCATION (Specify only highest grade I:;ompleled) <br />Elemental ~SeoOndary 10-12) College (1-4 or 5"'1 <br /> <br />.. <br />i 16. FATHER - NAME <br /> <br />FIRST <br /> <br /> <br />Katherine <br /> <br />A. <br /> <br />McHugh <br /> <br />LAST <br /> <br />17. MOTHER <br /> <br />MIDDLE <br /> <br />MAIDEN SURNAME <br /> <br />-: <br /> <br />Thomas <br /> <br />.. <br />- 'j'i'Cwi\S' DECEASeD eVER IN U,S. ARMED FORCES? <br />(Yes, nO. or unk.l 111 yes. give war and dales af services) <br />No <br /> <br />Alfred R. Smith, <br /> <br />19b. INFORMANT <br /> <br />MAILING ADDRESS <br /> <br />ISTREET OR R.F.D. NO" CITY OR TOWN. STATE. ZIPI <br /> <br />103 E. 14th <br /> <br />Grand Island, <br /> <br />NE <br /> <br />68801 <br /> <br />20. EMBALMER, SIGNATURE & LICENSE NO. <br /> <br />22a. <br /> <br /> <br />, l7~r <br /> <br />21a. METHOD OF DISPOSITION <br /> <br />21b. DATE <br /> <br />21c. CEME'lERY OR CREMATORy NAME <br /> <br />[]g Burial 0 Removal <br /> <br />Aug. <br /> <br />6, <br /> <br />2003 <br /> <br />Westlawn Memorial Park <br /> <br />21d. CEMETERY OR CREMATORY LOCATION <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />Apfel-Butler-Geddes <br /> <br />o Cremation 0 DonatlOIi <br /> <br />Grand Island, Nebraska <br /> <br />22b. FUNERAL HOME ADDRESS <br /> <br />(STREET OR R.F.D. NO. CITY OR TOWN. STATE. ZIPI <br /> <br />1123 West Second, <br /> <br />Grand Island, NE. <br /> <br />68801 <br /> <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal.lb). AND {ell <br />PART r, t? ----1; '-' tJ Ii <br />I'al l 52-~ r-O'~ (~~r- <br /> <br />DUE TO, OR AS A CONSEoueN~/7 /\^,..i./{,~,~ <br /> <br /> <br /> <br />In':;' betWJns.t and Oea'h <br /> <br /> <br />lnte--;val between on~ <br /> <br /> <br />~ I) ~ <br />~.---~ <br /> <br />Interval between onset Cind dealh <br /> <br />(01 <br />PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br /> <br />II <br /> <br />26a. <br />0 Accident 0 Undetermined <br />0 Sl,Jicide 0 Pending <br />0 Homicide Inv6stigatiorr <br /> <br />26b. DATE OF INJURY (Mo.. Day. Y'I 260. HOUR OF INJURY <br /> <br /> <br />M <br />26f, ~ffi~~gl,l~~I~~,J~~Y r&W,-fy" farm. street. factory <br /> <br />269. LOCATION <br /> <br />STREET OR R.ED. NO. <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />26.. INJURY AT WORK <br />Yes D No D <br /> <br />29. <br /> <br /> <br />260. DATE SIGNED IMo.. Day. Yr.J <br /> <br />28b TIME OF DEATH <br /> <br />_ _z <br />- " .. <br />Ill" <br />- .1i~ >- <br />:81E~ <br />- 1! f <br />: .e! <br /> <br />~~~ <br />~~~ <br />la:~~ <br />d~~~ <br />.s~~ <br />~~8 <br />8 " <br /> <br />M <br /> <br />260. PRONOUNCED OEAD (Mo.. Day. Yr.1 <br /> <br />28d. PRONOUNCED DEAD IHo",1 <br /> <br />M <br /> <br />M <br /> <br />2Se. On lhe basis of examination and, or investIgation, in my opinion death occurred at <br />the time. date and place ana dl,Je to the cause/g) stated. <br /> <br />30,b WAS CONSENT <>RANTED' <br />DYES <br /> <br />~NO <br /> <br />31, <br /> <br />Gordon J. <br /> <br />Custer, <br /> <br />Grand Island, NE. 68803 <br />32b. DATE AUG RE<>IS~AR2trrJjay Yr.1 <br /> <br />328, RE<>ISTRAR <br />