|
<br />~\ , STATE OF NEBRASKA - DEPARTMENT ~I H~L T~l~D HUMAN~E~V~~, 01' \ 3~g;(f6
<br /> L~H II"'ILAI~ F EA .. _, .. >, ',(. G,
<br />~ 1,OECEOENT'S,NAME (Flnot, Middle, Last, Suffix) ,2. sex. ..y",,,,,, T.I:W"o.O.y,Yr,)
<br /> I .~ WI \'. : .~.. . ,,'
<br /> Leland Harvey Smiley Mli'rEi.:-' ,~" NoVel;nbjit 29': 2007
<br /> 4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5.. AGE-L..t Blrthd.y Sb. UNOER 1 YEAR k.UND~ 1'D4~ '>~~'!44'l',Btlu-k IMI:>.. O.y. Yr.)
<br /> (Yno.) MOS. I DAYS HOUItS/ ~~;.,' ~i' ~~-"'". '~.- -' .
<br /> Deer Trail, Colorado 77 April 4, 1930
<br />'" 7. SOCIAL SECURITY NUMBER 8.. PLACE OF OEA TH
<br />~ 521-30-5890 llil&eIIAL; 0 Inp.llent 2IlWl: 0 Nunolng HornelL TC o Ho.plc. F.clllty
<br />f2 8b. FACILITY.NAME (If not In.tltullon, give .treet .nd nurnb.r) o ERlOutp.ll.nt iii Ducedenr. Horne
<br />&l
<br />D:: 417 N. Wetzel oOOA o Oth.rjSp.clfy)
<br />15
<br />oJ 80. CITY OR TOWN OF OEATH (Includ. Zip Cod.) ISd. COUNTY OF DEATH
<br />~ Grand Island 68801 Hall
<br />w
<br />z a.. RESIDENCE-STATE ab. COUNTY lac. CITY OR TOWN
<br />='
<br />ll.
<br />~ Nebraska Hall Grand Island
<br />"0 ad_ STREET AND NUMBER I 00. APT. NO. 1M. ZIP CODE I gg, INSIDE CITY LIMITS
<br /> Ql I!I y.. 0 No
<br />l;: 417 N. Wetzel 68801
<br />'1;
<br /> Ql 10.. MARITAL STATUS AT TIME OF DEATH IX! M.med o Nov.r M.m.110b. NAME OF SPOUSE (Flnot, Mlddl., Le.t. Suffix) If wlf., glv. rn.ld.n n'rne.
<br />~
<br />1! o M.m.d, but ..p.r.t.d 0 Widowed o Divorced o Un~nown Beverly Sutherland
<br />Q. 11. FATHER'S.NAME (Flr.t, L..~ SUffix) 112. MOTHER'S-NAME (First, Mlddl., Malden Surname)
<br /> E Mlddl.,
<br /> 0 Myrtle Evelyn Forehand
<br />(J David Archie Smiley
<br /> Ql 14b. RELATIONSHIP TO OECEDENT
<br />III 13. EVER IN U.S. ARMED FORCES? Glv. d.t.. of ..rvlc. If Y."114.. INFORMANT-NAME
<br />{? (Y... No. or Un~.) Yes Dates Unknown Beverlv Smilev Wife
<br /> 15. METHOD OF DISPOSITION lS.. EMBALMER.SIGNATURE I 18b. LICENSE NO. lSc. OATE (1,10.. D.y, Yr.)
<br /> oao,lol o Donation Not Embalmed November 30, 2007
<br /> (jj C.......n OEntombmlllnt lSd. CEMETERY, CREMATORY OR OTHER LOCATION CITYITOWN STATE
<br /> o R*rnov'" o Othlllr{Spl!t1;:lty)
<br /> Central Nebraska Cremation Service Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streat, City or Town, St.t.) l1b. Zip Cod.
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE OF DEATH (See Instructions and examples)
<br /> ii, PARt I. Enl.t th. ell.'n of .vOrlt:s . dl......, loJuri... or eompllcath:n\.- that dl,.t=tly CIIo8.d the dPdl. 00 NOt .nter terminal rRn" &uch .. cardiac arre8t, I APPROXIMATE
<br /> INTERVAL
<br /> relplralory arrut, or ventricular fibrillation without ..howlng UM "iOlogy. DO NOT ABBREVIA~ &n"r only on. caUtl on a IIn.. Add addltlonilllUna. tf rMlc....ry. I
<br /> IMMEDIATE CAUSE: onset to dUBth
<br /> IMMEDIATE CAUSE (Fln.1 I
<br /> diae..u or condition resulting .) C. ff r:- I / WK
<br /> In tJilla.th)
<br /> DUE TO, OR AS A CONSEQUENCE OF: I onsot to doeth
<br /> I
<br /> Sequentially lI..t condition_, If b) C Jl-D I 30 41-'5,
<br /> any. I..ding to the c:::aus. lI_t.d
<br /> on line 8. DUE TO, OR AS A CONSEQUENCE OF: onaet to death
<br /> I
<br /> Entar tho UNDERLYING CAUSE c) I
<br /> (di.ea.e or Injury th.t Inlll'led DUE TO. OR AS A CONSEQUENCE OF:
<br /> the events resulting In death) onset to death
<br /> LAST I
<br /> I
<br /> d) I
<br /> 18. PART II. OTHER SIGNIFICANT CONDITIONS,Condltlon. conlrlbullng to tho daath but not ra.ultlng In tho undarlylng causa glv.n In PART I. 18. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> (}DPn J ---ro8Ac.(O~tS use DYES crNO
<br />D::
<br />w 20. IF FEMALE: 21.. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />ii:
<br />~ o Not pregnant within pa8t year [W.Nalur.1 o Hornlcld. o Dr1v.rIOporator DYES ~NO
<br />W o progn.nt ot Ilrn. of death o Accident 0 P.ndlng In"..lIgatlon o P....ng.r 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />(J o Not pragn.nt, but pregnant within 42 d.y. of d..th o Sulcld. o Could not be datormlned
<br /> o P.d..IrI.n TO COMPLETE CAUSE OF OEATH?
<br />~ o Not pregnant, but pregn.nt 43 d.ys to 1 yea' before death o Other (SpeCify) DYES oNO
<br />~ o UnMown If pregnant within th. p..t y..r
<br />Q. I 22b. TIME OF INJURY 1 22c. PLACE OF INJURY-At horna, farm, .treet, f.ctory. offica building, con.trucllon .110. .tc. (Spaclfy)
<br />E 220. OATE OF INJURY (Mo., Day, Yr.)
<br />.0
<br />(J
<br />Ql
<br />III 22d.INJURY AT WORK? 122.. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />l- DYES oNO
<br /> 221. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITYITOWN STATE ZIP COOE
<br /> 23a. DATE OF OEATH (Mo.. Day, Yr.) ...~i:i 240. DATE SIGNED (1,10.. O.y, Yr.) 24b. TIME OF OEATH
<br /> 0: No~ ' .;19 ~OO'l
<br /> .:s m
<br /> ...!l .., !l~
<br /> i~> 23b. DATE SIGNED (Mo., O'y, Yr.) 1 23c. T'j~F: D~; A m f"'o 24c. PRONOUNCED DEAD (Mo., D.y, Yr.) 24d. TIME PRONOUNCED DEAO
<br /> _?il=>
<br /> ""0....J f'JO\J ;4.. ~ ,-=100 'l "" 0.. <( ..J
<br /> E ",0: ~ ~~ ~ m
<br /> 8c:0 23d. To tho best of rny knowledgo, d..th ~ at tha tlrne, data .nd pl.c. 24a. On th. b..le of examination and/or Inv..llg.tlon, In my opinion d..th occurred
<br /> Z'g <.>wo:
<br /> ~~~cau.e(:ited~ .nd Till.) J A '" "O::J at tha Ilrne, d.t. .nd pl.c. .nd dua to the c.u.e(.) .t.tad. (Slgnatura .nd TIll.)
<br /> ~~ "'00
<br /> ~~~
<br /> - 00
<br /> 25. DID TOBACCO USE C~~UTE TO THE DEATH? 126a. HAS ORGAN OR TISSU~ONATION BEEN CONSIDERED? I 28b. WAS CONSENT GRANTED?
<br /> ..B:.YES 0 NO PROBABLY 0 UNKNOWN o YES NO Not Appllc.ble If 28. I. NO 0 YES oNO
<br />} 27. NAME. TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Typ. or Prlnt)
<br />" I':f L A-1~ L HAt0'>E,.,) -.30 I u Lu, \::"''"t\)\..c '-\ A-(j\ C-I( lot ~\:) 1:-5 L l\f..l\) IJf (oK(O 3
<br />Alii
<br />v~ 28a. REGISTRAR'S SIGNATURE At,~ I~ A. f N4.#taa 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> DEe 5 2007
<br /> , . R' ... '., ...
<br /> v
<br />
<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 ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />
<br />
<br />:::;:::~:::::~TORY FOR VI2TALOROECSORODS2' 917 ~.tt!:;ER
<br />DEe 0 7 2007 ASSI$TA'N"r-~MiREQsj1MR,
<br />LINCOLN NEBRASKA HEALTt:l~NtYHUMJVi SEf:nI1Cts
<br />
|