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STATE OF NEBRASKA
<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, V/TAL STATISTICS SECTION,: WHICH 1S
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE •~ ;
<br />Tgi~~'Y3'~OR~R _.._
<br />LI~C~`LN N B~pO ~. 2 0 0 9 U 5 4 0 S /•~A~T ~"~M~°~.~__..
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<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SER4fN'S>rS %`.~~, r ..'3.._ s; ':~L,
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<br />Karon Yvonne Smith
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Burvvell, Nebraska
<br />?.SOCIAL SECURITY NUMBER
<br />84. FACILITY-NAME (Knot InstlWUon, piw street and number)
<br />Saint Francis Medical Center
<br />8c. CITY OR TpWN OF DEATH (Include ZIp Coda)
<br />Grand Island 68803
<br />se. RESIDENCE-STATE Bb. COUNTY
<br />Nebraska Wail
<br />Bd. STREET AND NUMBER
<br />OTHEB: ^ Nurelnp Home/LTC ^ Hospice Faclllry
<br />^ Decedents Home
<br />^ Other(8paciry)
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />fk. CITY OR TOWN
<br />Grand Island
<br />pe. APT. NO. 1N. LP GODE Bq. INSIDE CITY LIMITS
<br />207 N. Voss Road 88801 ®Y.e ^ No
<br />t0a. MARITAL STATUS AT TIME OF DEATH ^ Married ^ Never Married 10b. NAME OF SPOUSE (First Mlddlr, Laat, Suh1x) tl wHa, give maiden name.
<br />^ Mewled, butseparatad ^ Widowed ® Divorced ^ Unknown
<br />11. FATHER'S-NAME (Rnt, Middle, Laat SUNix)
<br />Walter David Neume er
<br />13. EVER IN U.S. ARMED FORCES? Give dates oT service Ir Yea. 14a. INFORMANT~NAME
<br />(Yea, No, or Unk.) NO Colin Smith
<br />18. METHOD OF DISPOSITION 18 LMER$ TU
<br />®Bunel ~^oonetinn
<br />^Cremadon ^Entgmtan.m ~
<br />12. MOTHER'S-NAME (Flret, Middle, Meldrn Surname)
<br />Norma Elaine Schuyler
<br />18b. LICENSE NO.
<br />^Remwal ^oen.depe~xyl 18d. CEMETERY, CREMATORY OR OTHE ATION
<br />Grand 1$land City Cemetery
<br />17a, FUNERAL HOME NAME ANO MAILINp ApDRESS (Street, Glty or Town, $htte)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CITYITOWN
<br />Grand Island
<br />GAUSE OF DEATH (See instructions and examples
<br />. PART I. L'emar }hq chain gr~wnd :~dlaue.., INudu, or compncntlonr ehu dincyy ciuwd the deadl. DO NoT emgi glminel wer,li such as cardyc emq,
<br />nepinhry amaL or wnWcular flbnlltlion wehget ahoWlna do adolggy. DO NOT pBBREVIATC. Enhr poly oM Nuea qn a IIM. Atld sddklonel Ilnu If neceeury.
<br />IMMEDIATE GAU5E:
<br />IMMEDIATE CAUSE (Final
<br />dlaeue or condition resuldnp a)
<br />In dash)
<br />DUE TO, OR A$ A CONSEQUENC
<br />Saquantlally Ilat conditions, IT b)
<br />any, leading to the cause listed C;
<br />on line a. pUE TO, DR AS A CONSEQUENCE OF:
<br />Enter the UNpERLYING CAUSE c)
<br />(disease or InJury that imtlatad
<br />the evenq resulting In death) pUE Tp, OR AS A CONSEQUENCE OF;
<br />LASr
<br /> d)
<br /> 18. PART II.OTHER SIpNIFIGANT CONDITIONS-Conditions contdbu0np to the de
<br />ath
<br />but not naulUnp in the underlying cause
<br />given in PART L
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<br />/-~-ve..r ~~/e'~ ~~n. ~ ~C..c y, G~ rC~-c.../r"~v
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<br />~/Im'1- 7'/<. "~'
<br />a ~
<br />W Rq IF FEMALE;
<br />of pregnan! wlfhin
<br />eat ~71t. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR
<br />~ p
<br />year atunl ^ HomlOlde ^ Ddvar/Operetor
<br />W ^ Pnpnant at time of death ^ Accident
<br />^ Pendinglnvesdpatlan
<br />^ Paasengar
<br />~ ^Not pregnam, but praprwnt within 42 drys of death ^ Suicide ^ Could not be detartnlnad ©Pedastdan
<br />.~' ^ Not pregnant, but pregnant 43 days to 1 year before death ^ Other (Spadry)
<br />9
<br />4~
<br />^Unknowrrlf pregnant wllhln iha past year
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />i8c. PATE (Me., pay, Yr.)
<br />December 6, 2007
<br />STATE
<br />Nebraska
<br />17b.Zip Code
<br />68801
<br />I onset !o doath
<br />omet to death
<br />I
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<br />onwe to death
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<br />onset tO death
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<br />19. WAS MEDICAL EXAMINER
<br />OR CORONERMCIONTACTED7
<br />© YES ~ NO
<br />R1c. WAS AN AUTQPS,Y PERFORMEp7
<br />^ YES ND
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />^ YE$ ^ Np
<br />0 22a. DATE OF INJURY (Mo., Day, Yc) 22b. TIME OF INJURY 22c. PLACE OFINJURY-At home, ramp street, Tactory, oRice building, conahuctlon alto, ela. (Speclry)
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<br />m R2d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURREp
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<br />~ ~ ^YES ^ NO
<br />22f, LOCATION OF INJURY-STREET 6 NUMBER, APT. Nq. CITYITOWN
<br />23a. DATE OF DEATH (Mo„ pay, Yr.)
<br />~'~ tavember 29 , 2007
<br />~ Rib. DATE SIGNED (Mc., Day, Yr.) Ric. TIME pF DEATH
<br />~'~~ ecember 3 2007 11:20 P m
<br />c~
<br />e lad. To the Wee of my krJowl dge, death occurred at the tlme, date and place
<br />~ ~ and due to tha..o '~ ` led. ($Ipnature and Title)
<br />_~~
<br />71
<br />8a. PLACE OF DEATH
<br />H48PITAL: ©Inpatlem
<br />® ER/OulpaUant
<br />^ DOA
<br />STATE LP CODE
<br />R4a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME pF pEATH
<br />~~~ m
<br />O lac. PRONOUNCED DEAD (MO„ Day, Yr.) Rod, TIME PRONOUNCED DEAp
<br />~r
<br />ayQ C m
<br />W ~ 24e, Dn the basis of sxaminatlon and/or Invutlgadon, In my opinion death occurred
<br />C ~ O at the Ume, data and place end due to the cauw(s) stated. (Signaturo and TIUe)
<br />F t7
<br />yo
<br />25. DID~TO~ACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS ORGAN OR TISSU NATION BEEN CONSIDEREp7
<br />YES ^ NO ~ ^ pRDeABLY ^ UNKNOWN ^YES ~NO
<br />27. NAME, TITLE AND DRESS pF CERTIFIER (PHYSICIAN, CgRONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Dr Jane~A McDonald MD 1300 Al ha Grand
<br />28a. REGIS'TRAR'S SIGNA URE ,(
<br />P '~ ~(J • ~,'t,
<br />a
<br />.J SJ L:LU .:
<br />DATE pF DEATH (Ma;pay,Yr.) . .
<br />v eT'~9, ~00~°
<br />DATE t7F'BIRTH o.. bay, Yc)
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<br />Novembel• 1; 1936
<br />Ba. AGE•Lset Birthday eb. UNDER 1 YEAR tk. UND
<br />(Yre.) MOS. DAYS HOURS
<br />28b. Wq8 CONSENT GRANTED?
<br />Not Appllwble H 28a is NO ^YES
<br />28b, DATE FILED BY REGISTRAR (Mo., Dey, Yr.)
<br />nE~ r o 200
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