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<br />
<br />STATE OF NEBRASKA . " .,}'ii;,.I"''i>;,
<br />" ';,(..,. ",. ,\'c, ,.,.,
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ~i!!!..MM{ditR.VICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIG/~~gl}tl9J!fliElb~E'v.;1TH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST1J}!?!f!.!.1i.'~lJ"i1l9~fJ!lEH:,IS."
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.. . cH" ,-,u~,~"~:&"."'--,'~,-,i-~,,'iO,,o',C,:,;X,',"l,~,:,',.',~,,"~,",.~ ~~~~, --,: ',ft"~j,
<br />
<br />DAJTAENOFO/S:UAlNOCOEl 'lr11r "~A~I",.e~ieR'
<br />u 200903900 ~~~~~~~~~R
<br />LINCOLN, NEBRASKA HC~T~'t'"'~-.:J!t;R$!CES
<br />-'P~ii~Lt~):- !i~~7
<br />
<br />STATE OF NEBRASKA ~ DEPARTMENT OF HEALTH AND HUMAN SERVICES FINA~8i=,"~N5-:SU1f~T 2 O. 0 O.
<br />CERTIFICATE OF DEATH '.-- iC, U I
<br />
<br />1. DECEOENT'S-NAME (Flr'H,
<br />
<br />Harr
<br />
<br />Mlddl.,
<br />W.
<br />
<br />lasl,
<br />Smith
<br />
<br />Suffl.)
<br />
<br />2,SEX
<br />Male
<br />
<br />3, DATE OF DEATH (Mo" Day, Yr,)
<br />01 02' 2007
<br />
<br />Wood River,Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />506-58-7713
<br />
<br />63
<br />
<br />
<br />6. DATE OF BIRTH (Mo.. Day, Yr.)
<br />
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />5., AGE-last Birthday 6b, UNDER 1 YEAR
<br />(Yr.,) MOS, DAYS
<br />
<br />80_ PLACE OF DEATH
<br />1:\.QID'JJAl.:
<br />
<br />XXlnp.lI.nl
<br />
<br />QlliEfl: 0 Nur.lng Home/lTC 0 Ho'plc. Facllily
<br />
<br />8b, FACiliTY-NAME (If nol Inslllullon, glva .Ir..1 .nd numb.r)
<br />
<br />o ER/Oulp.lI.nl
<br />
<br />o D.cadanl'. Homo
<br />
<br />Nebraska Heart Hospital
<br />8c, CITY OR TOWN OF DEATH (Includ. Zip Coda)
<br />Lincoln 68526
<br />
<br />o CO\ 0 Olhar (Sp.clfy)
<br />ad, COUNTY OF DEATH
<br />Lancaster
<br />
<br />g., RESIDENCE.STATE
<br />Nebraska
<br />9d, STREET AND NUMBER
<br />507 N. Waldo
<br />10., MARITAL STATUS ATTIME OF DEATH ~ M.rrlad 0 Nav.r M.rrl.d
<br />
<br />9b, COUNTY
<br />Hall
<br />
<br />
<br />91, ZIP CODE
<br />68803
<br />
<br />9g, INSIDE CITY LIMITS
<br />XXYES 0 NO
<br />
<br />lOb, NAME OF SPOUSE (FlrsI, Mlddl., last, sum.) II wlf., glv. maldan n.m..
<br />
<br />o Marrl.d, bUl.ap.r.lad 0 Wldowad 0 Divorced 0 Unknown
<br />
<br />Beverly Thomson
<br />
<br />11. FATHER'S-NAME (Flr.l,
<br />Fred
<br />
<br />Mlddla,
<br />
<br />la'l,
<br />
<br />Sulll.)
<br />
<br />12, MOTHER'S.NAME (Flr.l,
<br />Rose
<br />
<br />Middle,
<br />
<br />M.ld.n Surname)
<br />
<br />Smith
<br />
<br />CITY / TOWN
<br />
<br />nn n
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Wife
<br />16c, DATE (Mo" Day, Yr, )
<br />
<br />Januar 4 2007
<br />STATE
<br />
<br />13, EVER IN U,S, ARMED FORCES? Glv. dale. of .a,vlc.1I yes, 14..INFORMANT.NAME
<br />No Beverl
<br />
<br />15, METHOD OF DISPOSITION
<br />o Burial 0 Donallon
<br />JOcr.mallon 0 Enlombmenl
<br />o Remov.1 q Olhar (Spaclfy)
<br />
<br />16a, EMBAlMER.SIGNATURE
<br />
<br />Not Embalmed
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER lOCATION
<br />
<br />
<br />16b, LICENSE NO,
<br />
<br />Aspen Crematory
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (SIr..', CUy or Town, Sial.)
<br />
<br />Livingston-Sondermann Funeral Home,60l
<br />
<br />Lincoln
<br />
<br />Nebraska
<br />17b, Zip Cod.
<br />Island, NE 68803
<br />
<br />18, PART I. Enl.r th. ch.ln ol.v.nl.--dlse...., InJur'.s, or compllcallon...lh.1 dlr.clly cau..d Ih. dealh, DO NOT .nl.r larmln.' ov.nl. .uch .. c.rdl.c .rr.."
<br />ra.plralory arresl, or v.nlrlc"'.r IIbrlllallon wUhoul Showing Ih. ellology, DO NOT ABBREVIATE, Enlar only on. c.use on alln.. Add .ddltlonalIIn..II nec....ry.
<br />
<br />::MEDlATECAUZO:'l"t.-Q_t''CA C .(:;; I VI I XL.
<br />
<br />~UE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(b) C O{()V"'\(,.,( {, (){,- '-}-/j r~<
<br />DUE TO, OR AS A CONSEQUENCE OF'
<br />
<br />on..' 10 daalh
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl..... or condlUon r..olllng
<br />In de.lh)
<br />
<br />onsello dealh
<br />
<br />Sequanllally 1111 condlllon.,II
<br />.ny, I..dlng 10 Ih. cau..II.lad
<br />On line a.
<br />Enl.r lhe UNDERLYING CAUSE
<br />(dl..... or Injury Ih.llnltl.,.d
<br />th. .vonlB ","ulllng In d.alh)
<br />lA5f
<br />
<br />
<br />"'. '"~ )""T~"~
<br />","'f , '>.,
<br />\ . . , '
<br />:: '- "e,
<br />
<br />cn..llo dealh
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on..llo d..lh
<br />
<br />(d)
<br />
<br />18, PART II, OTHER SIGNIFICANT CONDIT'ONS-Condltlon. conlrlbullng 10 Ihe d..lh bUI nol re.ultlng In Iha undarlylng C'U.a glvan In PART I,
<br />
<br />20, IF FEMALE:
<br />o Nol p,egn.nl wUhln p..1 ya.,
<br />o Pragnenl at 11m. of d.alh
<br />o Nol pr.gn.nl, bul pragn.nl wUhln 42 day. 01 d.alh
<br />o Nol pr.gn.nl, bUI pragn.nl43 d.y. 10 1 yaar b.for. d..lh
<br />o Unknown II pregnanl wllhln Iha p.st ya.r
<br />
<br />21., MANNER OF OEATH
<br />
<br />''''''''''@.f)I.lur.' 0 Homlcld.
<br />..~
<br />
<br />o AccidanlO P.ndlng Inv..IIo.lIon
<br />
<br />o Sulclda 0 Could nol be d.l.rmlned
<br />
<br />21b, fFTRANSPORTATION INJURY
<br />o Drlv.r/Op.r.lor
<br />
<br />o Passenge,
<br />
<br />o Pad..lrl.n
<br />
<br />o Olhar (Sp.clly)
<br />
<br />19, WAS MEOICAl EXAMINER
<br />OR COIJI)NER CONTACTED?
<br />o YES ~,NO
<br />21c, WAS AN AUTOPSY PERFORMED?
<br />
<br />o YES "~
<br />
<br />DYES 0 NO
<br />
<br />
<br />21d, WERE AUTOPSY FINOINGS AVAILABLE TO
<br />COMPLETE C~SE OF DEATH?
<br />DYES "'1Sl. NO
<br />
<br />22s, DATE OF INJURY (Mo" O.y, Yr,)
<br />
<br />22b, TIME OF INJURY 22c, PLACE OF INJURY.AI hom., lerm, .Ir.." I.clory, olllca bUilding; CO"Irucllon .11., .Ic, (Sp~cIfYJ
<br />m
<br />
<br />22d, INJURY AT WORK?
<br />
<br />22f.LOCATlON OF INJURY. STREET & NUMBER, APT. NO,
<br />
<br />. CITYtrOWN
<br />
<br />SWE
<br />
<br />ZIP CODE
<br />
<br />24.. OATE SIGNED (Mo" O.y, Yr,)
<br />
<br />24b. TIME OF DEATH
<br />
<br />m
<br />
<br />~~~
<br />g'!a:
<br />h5~
<br />~ .,,~ ~
<br />.8~:::>
<br />,g~8
<br />85
<br />
<br />m
<br />
<br />24c. PRONOUNCED DEAD (Mo" D.y, Yr,) 24d, TIME PRONOUNCED DEAD'
<br />m
<br />
<br />246. On Ihe basla of examlosllon and/or InveslIgalloll,ln my opInion dealh occurred"ai"
<br />1110 lima, dol. .nd pl.c. and ~ue 10 Ih. cau..(.) .1.lad, (Slgn.lur. .nd Tille) T
<br />
<br />DYES 0 NO 0 PROBABLY NKNOWN 0 YES NG
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER' (P YSICIAN, CORONER'S PHYSICIAN OR COY TY ATTORNEY) (Typa or Prlnl)
<br />
<br />James H. Wudel M.D. Nebr. Health lnst. P.O. Box 8258
<br />
<br />. 26b, WAS CONSENT GRANTED?
<br />Nol Appllcabla II 260 I. NO 0 YES 0 NO
<br />
<br />Lincoln NE 68
<br />28b, DATE FllEjA ~GIURt (10 trr. Yr,)
<br />
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