|
<br /> STATE OF NEBRASKA
<br />
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL1'hk',A M"~A~I Gf- VI'CE$,'IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE IYEBPA,V,'KA 3Crr i 1AJ &T O1N' TH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR lrl~
<br /> DATE OF ISSUANCE
<br /> f i ~ I r
<br /> SGr Q ZDO SSA7ULEl S CQOP
<br /> SrgNAs7RA~'~ .
<br /> 201003658 DEPARTMENT Ofr rH `AL Area; :
<br /> LINCOLN, NEBRASKA HLlM/I~-SEy~CL~S e r '
<br /> STATE OF NEBRASKA-- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND S'q. tP -1 1
<br /> ~ O7
<br /> _ CERTIFICATE OF DEATH w rU'
<br /> 1` DECFDENT'S-NAME (First, - Middle, Last, Suffix) 2. SEX 3. DATE OF'DEATH (Mo:, Day,'(,) -
<br /> Wesley A Smith Male August 21,2009
<br /> _ 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Lael Birthday 5b. UNDER 1 YEAR 50- UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.j
<br /> Belton, Missouri (Yrs.) 80 MOS. DAYS HOURS MINS. May 24 r 1929
<br /> 7. SOCIAL SECURITY NUMBER M as, PLACE OF DEATH
<br /> AJ2-16-5$ra2 HOSPITAL: ❑ Inpatient Me: 91 NursingHome/LTC OHospiceFacillty
<br /> Bb. FACILITY-NAME If not institution, give Iva street and number) ❑ ERIOutpalient ❑ Decedent's Home
<br /> Wedgewood Care Centex
<br /> ❑ DCA ❑ Other (Specify )
<br /> 8c. CITY OR TOWN OF DEATH (Include Zip Code) ed. COUNTY OF DEATH
<br /> Grand Island 68803 Hall
<br /> 9e. RESIDENCE-STATE 9b.CpUNTY u- 9c, CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> 9d. STREET AND NUMBER _ go. APT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
<br /> 122 Voss Road 68801 % YES Q NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH A Married Q Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) 11 wife, give maiden name.
<br /> Q Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br /> Glad s A. Deml3hltl _
<br /> 11. FATHER'S' NAME (First, Middle, Last, suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> Martin H. Smith Fannie E. Kinnison
<br /> 13. EVER IN U.S. ARMED FORCES? Give dales of service 11 yes. 14a. INFORMANT-NAME w. 14b. RELATIONSHIP TO DECEDENT
<br /> (Yes, no, orunk.) Rp Gladys A. Smith Wife
<br /> 1 15. METHOD OF DISPOSITION 168-EMBAL A- IG TUR 18b. LICE~S~N 18c. DATE (Mo.., Day, Yr.) -
<br /> 2Burial ❑Donation 1 August 24, 20.0-9..,,
<br /> 1 : CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE.
<br /> Q Cremation ❑ Entombment .
<br /> ❑Removal ❑431her.(SPeafy) Westlawn Memorial Park Cemetery, Grand Island, Nebraska
<br /> i7a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Stale) 11b. Zip Cod(,
<br /> Kleine FLmeral Home, 3213 W North Front St., Grand Island, NE 68803
<br /> I
<br /> 18. PART I. Enter the, chain ej "golif-Alseases, injuries, or complications.-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTEPV~L >
<br /> respiratory arrest, or ventricular Ilbrillallon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. -
<br /> IMMEDI CAUSE: - onsel to death
<br /> IMMEDIATE CAUSE (Final (a) _a h (1. L/_4'
<br /> disease or condition resulting DUE TO, OR AS A CONSEQUENCE OF: I onset loo Ih~
<br /> In death) I
<br /> Sequentially list conditions, if (b)
<br /> k - ~
<br /> any, leading to the cause listed DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br /> on line a. I
<br /> Enterthe UNDERLYING CAUSE
<br /> (disease or Injury that initialed (c) _
<br /> the events resulting In death)
<br /> DUE TO, OR ASACONSEQUENCE OF: I onset to death
<br /> I
<br /> Id) i
<br /> _ 10. PART It. OTHER SIGNIFICANT CONDITIONS•Condilions contributing to the death but not resulting In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> r~. Q YES ❑ NO
<br /> 29. IF FEMALE: 21a. MANNER OF DEATH 211b.IFTRANSPORTATIONINJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> W
<br /> EfNalural ❑ Homicide Q Driver/Operalor
<br /> ;pry O Not pregnant within past year Passenger Q YES R(NO
<br /> ppCC ❑
<br /> C3 Pregnant at time of death ❑ Accidenl❑ Pending Investigation U1'
<br /> T^ ❑ Pedestrian
<br /> its ❑ Not pregnant, but pregnant within 42 days of death Q Suicide Q Could not be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> r€o.;~
<br /> 3a
<br /> h$Fi ❑ Not pregnant, but pregnant 43days to tyear before death ❑ other (Specify) COMPLETE CAUSE OF DEATH?
<br /> ❑ Unknown 11 pregnant within the past year ❑ YES ❑ NO
<br /> 22a. DATE OF INJURY (Mo., Day, Yc) 226. TIME OF INJURY 22c. PLACE OF INJURY-At home, term, street, factory, office building, conslrllction site, etc, (Specify)
<br /> dre !p m
<br /> f to
<br /> 22d. INJURY ATWOFK? DESCRIBE HOW INJURY OCCURRED
<br /> 1 ❑ YES L) NO
<br /> - - 221. LOCATION OF INJURY - STREET A NUMBER, APT. NO. CITY/FOWN 5TArE ZIP CODE
<br /> 23a. DATE OF DEATH (Ma., Day, Yr.) z - 24s. DATE SIGNED (Mo., Pay, Yr.) 24b. TIME OF DEATH
<br /> 3 W
<br /> 23b.DATE SIGNED (Mo.,Day, Yr.) 23o,TIMEOFDEATH r 24c.PRONOUNCEDDEAD(Mo.,Day,Yf.) 24d. TIME PRONOUNCED DEAD
<br /> _ _ IT m
<br /> ~
<br /> 23d. To Iha beet of my knowledge, death o red al the time, date and place 190 24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br /> g and d e to the cause(s) slated. (Si a re end Tills) g p the time, date and place and due to the cause(s) staled. (Signature and Title) r
<br /> 10
<br /> .(5. UIOTOBA OUSE CONTR BUTETO THE DEATH? 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ❑ YES N NO PROBABLY El UNKNOWN El YES NO Not Applicable it 26a is NO ❑ YES Q NO
<br /> 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN.CORONEWS YSICIANORCOUNTYATTORNEY) (Type or Print) Larry ansen 7 De
<br /> nee I , ~ ic1La G •C nAT 14r~c1
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> AUG 2 6 2009
<br /> HHS-fit 1110y(550d1)
<br />
|