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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINItL~-C!, FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA'r!!ffl!;;$~~r!~i)!,!HICH IS
<br />
<br />::::=::;TORY FOR VITAL RECORDS. ~T!l.?fltPER'
<br />OCT' 2 8 2005 200700 0 G 8 '~A$~/STA'NT STATE'Rfp1~"RAR
<br />LINCOLN, NEBRASKA ilfAL.rH ~ND ~~MA_I'J'SEtl!'CES
<br />
<br />~=,i".
<br />
<br />
<br />STATE OF NEBRASKA --' DEPARTMENT OF HEALTH AND HUMAN SERVICThF!NAN9~g.t,Il;t~PORT . 9 6
<br />_~E_J:lTIFJG~TE_O r:=_[)_;~It:!____ ._~_n_"'::_:~~___ ..,__D5.__.11__5____
<br />DECEDENT'S-NAME (Firsl, Middle, Last, Suffix) 2, SEX - 3, DATE OF DEATH (Mo" D~, Yr,)
<br />G~ne R~land Smith Male October 24, L005
<br />
<br />4_ CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5e, AGE-Lasl Blrlhday 5b, UNDER 1 YEAR
<br />(Yrs.) MOS_ DAYS
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr,)
<br />
<br />Hasti ngs_LNe~!"as_ka
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />53
<br />
<br />November 13, 1951
<br />
<br />508-62-2424
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<br />6a, PLACE OF DEATH
<br />!:iQ.SPITAL:
<br />
<br />l(Ilnpalient
<br />
<br />QIH~8: O' Nurslog Home/LTC 0 Hospice Facilily
<br />
<br />8b, FACILITY-NAME (II nol Inslilulion, give slreel and number)
<br />
<br />o ER/Oulpallent
<br />
<br />o Decedenl" Home
<br />
<br />Heart Hospita
<br />
<br />OlD'.
<br />
<br />o Olho!(Specil;L___ ______._
<br />
<br />8d. COUNTY OF DEATH
<br />
<br />Lancaster
<br />
<br />91. ZIP CODE
<br />
<br />_lQO$Jtr~_DTh'O od_$qqj-m:~__________ _....Q88 0 1
<br />lOa. MARITAL STATUS AT TIME OF DEATH XJ Married 0 Never Married 10b_ NAME OF SPOUSE (Flrsl, Middle, Lest, Suffix) II wife, give melden name,
<br />
<br />
<br />99_ INSIDE CITY LIMITS
<br />~ YES 0 NO
<br />
<br />o Married, but separa.ted 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Debra Schiefelbein
<br />
<br />11. FATHER'S-NAME (Firsl,
<br />Hal
<br />
<br />Middle,
<br />
<br />Lasl, Suffix)
<br />Smith, Sr.
<br />
<br />12_ MOTHER'S-NAME (First,
<br />Mar er
<br />
<br />Maiden SUrname)
<br />Galle
<br />14b, RELATIONSHIP TO DECEDENT
<br />Wife
<br />] 16b L1C_EN_S_E N__O_,--__- - - -- -- 160, DATE (MO" D~y, Yr,) ____om
<br />_ ___ Octop_er 26, _10_0~
<br />CITY / TOWN STATE
<br />
<br />Middle,
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<br />13. EVER IN U,S, ARMED FORCES? Give dales 01 service If yes, 14., INFORMANT-NAME
<br />No Debra Smith
<br />
<br />15, METHOD OF DISPOSITION
<br />
<br />OButlel
<br />
<br />o Donalion
<br />
<br />16a. EMBALMER.SIGNATURE
<br />
<br />Not Embalmed
<br />16d_ CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />~ Cremellon 0 Enlombmenl
<br />
<br />o Removal 0 Olher (Specify)
<br />
<br />Lincoln Cremation Service
<br />
<br />Lincoln
<br />
<br />Nebraska
<br />
<br />PART I. Enler Ihe ~~..diseases, injurie., or complicallon'uthal dlreclly caused Ihe deelh, DO NOT enler lermlnalevenl. such a. cardiac arre.I,
<br />respitalory .tresl, or venfricular IIbrillalion wilhoul showing Ihe ellology. DO NOT ABBREVIATE, Enter only one cause on . line, Add addlllonalllne. If nece.sary,
<br />
<br />
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, CllyorTown, Stal.)
<br />DeWitt Funeral Home & Cremation Service, 1247
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condlllon r.,ultlng
<br />In deefh)
<br />
<br />IMMEDIATE CAUSI':
<br />
<br />(a) (Ol"i;!t;>t( l~_~JI/!{________
<br />
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />(b) /J (;I';fl,. S?14-10 1;1
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />ol"isal to de'Sl!h
<br />
<br />Sequentially lI.t condition., If
<br />.ny, le.dlng to tha ceu.ell.ted
<br />on Iin@3.
<br />Enler Ihe UNDERLYING CAUSE
<br />(dl..... or InJUry that Inltl.ted
<br />Ih. .v.nl. re.ulting In death)
<br />LAS!'
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />I
<br />I
<br />__-----L
<br />I onsello death
<br />I
<br />I
<br />I
<br />I on.ello dealh
<br />I
<br />I
<br />
<br />".L._"_ __ ______
<br />I ons.llo death
<br />I
<br />I
<br />
<br />(d)
<br />
<br />o AccidenlO Pending Investigation
<br />
<br />21 b, IFTRANSPORTATION INJURY
<br />o Drlver/Operetor
<br />
<br />o Pa..enger
<br />
<br />o Pedestrian
<br />
<br />'""=-r--w" m_.____.________
<br />19_ WAS MEDICAL EXAMINER
<br />OR CORONER CJNTACTED?
<br />o YES ~ NO
<br />_0"'.'_. "".._. ,__.,
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />fa, PART II. OTHER SIGNIFICANT CONDITIONS-Condlllons conlrlbuling 10 Ihe death buf not resulling In Ihe underlying cause given in PART I.
<br />
<br />~
<br />
<br />:fi~
<br />
<br />
<br />
<br />':l~^ 0 Not pr.gnanl, bul pregnanl wilhin 42 day. 01 dealh
<br />
<br />"I 0 Nol pregnant, bul pregnanl43 days 10 1 yearbelore dealh
<br />; i
<br />~"J , (J Unknown If pregnant within the past year
<br />
<br />i~'. - -;'2a DATE OF INJURY (Mo , Day, Yr) 22b, TIME OF INJUR:
<br />
<br />
<br />
<br />I ~':"::;;::'
<br />
<br />fiT ___1...__..
<br />
<br />I.:' '~~:;;;;;:;;' :':;~:'5m", =-. ~ ia: ;~~'^" ;;rn;H>~:ii;",,} ~ ='"' O>"'~ m
<br />
<br />
<br />;,}i~; ]l ~ 23c_ TIME OF DEATH II ~ ~ 24c, PRONOUNCED DEAD (Mo" Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />):1:i\J.:II~~~ 12:10 pm lil:!;;:::;
<br />'V}tfiin.z E"'i:z m
<br />'.,.J.i.~.i.':.'~.'Jj(,,:~.i.:,,:::,::' ! ~ 0 ~ UJo= ~o 0 2413. On the basis of examination and/or investigation, in my opinion death occurred at
<br />. "" ~ .0 Ihellme, dale .nd place .nd due 10 Ihe cause I') slefed_ (Signalure and Tille) ...
<br />i~:'i {2 ! {!. a: <>
<br />
<br />...,.1t.~.I~ ~ . 26., HAS ORGAN OR TISSU; ;NATION BEEN CONSIDERED?
<br />
<br />1~;1: 0 YES 0 NO lJ PROBABLY JUNKNOWN 0 YES ~ NO
<br />~~~,~: -- 27: NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN-;CORONEF'I'S PHYSiCIAN OR COUNTY ArrORNEY) (Type or Print)
<br />,~~ James H. Wudel, res, 1500 South 48th Street, Suite 800, Lincoln, Nebraska 68506
<br />
<br />
<br />t'~'.M.. -V. "~:V\iJL
<br />
<br />o Not pregnanl wllllln pSSI year
<br />o Pregnant at lime 01 death
<br />
<br />21a. ~AYNER OF DEATH
<br />Y'Nalural 0 Homicide
<br />
<br />DYES
<br />
<br />"'NO
<br />
<br />o Suicide 0 Could nof be defermlned
<br />
<br />21d. WERE AUTOPSY FINDiNGS AVAILABLE TO
<br />
<br />o Olher (Specify)
<br />
<br />COMPLETE CAUSE OJ DEATH?
<br />o YES I5i NO
<br />
<br />220. PLACE OF INJURY-At home, farm, street, factory, office building, construction sile, etc. (Specify)
<br />
<br />
<br />N~~c~1 2015
<br />
<br />28b_ WAS CONSENT GRANTED?
<br />
<br />NOI Applicab!e il 26. Is NO 0 YES
<br />
<br />rlo
<br />
<br />2aa, REGISTRAR'S SIGNATURE
<br />
<br />28b, DATE FILED BY REGISTRAR (MO" Day, Yr,)
<br />
<br />OCT
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