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WHEN THIS COPY CARRIES TM RAISED SEAL OF THE NEBRASKA HE/ SYSTEM, IT CERTFIES TFA: BELOW TO BE A TRUE COPY OF THE OR/G THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL 90 THE LEGAL DEPOSITORY FOR VITAL RECORDS I' DATE OF ISSUANCE , A; 10/26/2004 200500965 AS LINCOLN, NEBRASKA HEAL F, AN& STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HIA4AN.§ VITAL STATISTICS- CERTIFICATE OF DEA'T] 4T,H AND HUMAN SERVICES QN FILE WITH FT�Sk - ,i1WCH IS 11553 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX: ATE OF DEATH /Month, Day. Year) Delpha Arlouine Smith Female October 9, 2004 4. CITY AND STATE OF BIRTH /Il not M U.S.A.. name country) 5a. AGE -Last Birthday I UNDER _1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Year) .MOS. DAYS 5c. HOURS' MINT North Loup, Nebraska (Yrs.l 87 SbI O April 4, 1917 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF DEATH 508-16-9107 HOST_ ITAL. ❑ Inpatient OTHER: ❑ Nursing Home ❑ ER Outpatient Residence 8b. FACILITY -Name f frol institubon, give street and number) 2 717 W. Louise ❑ DOA ❑ Other (Specitivl Sc. CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island Yea ® No F_] Hall 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /lncluding Zip Code) 68803 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 2717 W. Louise Yes N] No 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican, German, etcl 12. ❑ MARRIED ® WIDOWED 13. NAME OF SPOUSE /d wile. give maiden name) etc.) IS White (Specify American NEVER DIVORCED R 14a. USUAL OCCUPATION /Give kind of work done during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) o / working life. even if retired) Homemaker Own Home 1a Secondary to - , z) College n -4 or 5•1 16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Bert Williams Stella Fuller 18, WAS DECEASED EVER IN U.S. ARMED FORCES? 19a INFORMANT - NAME (Yes. no. or unk.l (if yes. give at and dates of services) 7 No I Barbara Hull 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 666 Re nedy Drive #11, Grand Island, Nebraska 68803 20. M MER - NO. 21 a. METHOD OF DISPOSITION 21b. DADAIT.E� ccCEtMETERY OR CREMATORY NAME G' #1071 WE ®Burial ❑ Removal •fAff X21 wadi 12, LW4 LVi ua jjX1�i He y 21- a. FUNERAL HOME - NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE All Faiths Funeral Home ❑ °femati°" ❑DOnd North Loup, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 2929 S. Locust St., Grand Island, Nebraska 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). Ibl, AND (c)l I Interval between onset and death PART I I 1 (al Natural Causes - I unknown DUE TO. OR AS A CONSEQUENCE OF I Interval between onset and death I I @I DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death I I (cl I OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? 125. EXAMINER OR CORONER? II (Ages 10 -541 Yes No Yes No is Yes W No 26a. 26b. DATE OF INJURY 1W.. Day. Yr) 26c. HOUR OF INJURY 26d DESCRIBE HOW INJJRY OCCURRED Accident El Undetermined M ❑ Suicide F Pending 26e. INJURY AT WORK 26f. PLACE INJURY -At tome. farm. street. factory bull SSP�e,ciiffYyl) 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ office etc. 27a. DATE OF DEATH (Mo.. Day. Yr.) 28a. DATE SIGNED ifili Day. Yr.) 28b. TIME OF DEATH /0 - approx 2:00 am ai as 27b. DATE SIGNED (Mo.. Day. Yr.) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD Iti Day, Yr.) 28d. PRONOUNCED DEAD iHourl 2 =0 M� 10 -9 -04 5:12 aM BE $a 27d. To the best of my knowledge. death occurred at the time, date and place and due to the 26e. On the basis of examination and,or irwesti m j ooin�on death occurred at < ° ~ cause(sl stated. / ° 0 the time, date and dace o e cau I stated .l nature and Title ► '+�i/ (Si nature and Ttle ► 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CO ANTED? ❑ YES ❑ NO 7 UNKNOWN ❑ YES ® NO ❑ YES ® NO Jl. NAM( ANU AUDHtJJ Vh I:CYI l lrltrl IYM TJIli1N1V, IiVMVIVCM J YI- ITJIVIMry Vr� IiVUIY 1 T M I I V�rvCi I 1 r yj-- -1111