NON-CERTIFIED RECORD OF DEATH

FOR ADMINISTRATIVE USE ONLY PRINT DATE: 07/14/2017

STATE FILE NUMBER : 2017-MN-017008 LEGAL DATE FILED : May 16, 2017 MEDICAL DATE FILED : June 16, 2017
FIRST NAME : PETER DATE OF DEATH : May 14, 2017
MIDDLE NAME : WILLIAM DATE OF BIRTH : February 23, 1936
LAST NAME : SMITH GENDER : Male
LAST NAME PRIOR TO FIRST MARRIAGE: SSN : 004349444
SUFFIX : AGE : 81 Year(s) Month(s) Day(s) Hrs Min
ALIAS : BIRTH PLACE : City : PORTLAND State : MAINE Country : UNITED STATES
FATHER'S NAME : WALDO STERLING SMITH MARITAL STATUS : MARRIED
MOTHER'S NAME : HARRIET HAWKINS SURVIVING SPOUSE'S NAME : JANET SHARON LANGENFELD
RACE : WHITE USUAL OCCUPATION : OWNER/CEO
HISPANIC ORIGIN NO, NOT SPANISH/HISPANIC/LATINO KIND OF BUSINESS / INDUSTRY : BUSINESS INVESTER
EDUCATION : MASTER'S DEGREE (E.G., MA, MS, MENG, MED, MSW, MBA) EVER IN U.S. ARMED FORCES : Yes
RESIDENCE : 596 CHEROKEE ROAD LAKE FOREST ILLINOIS 60045 INFORMANT'S NAME : JANET SMITH
COUNTY : LAKE RELATIONSHIP TO DECEDENT : SPOUSE
INSIDE CITY LIMITS : Yes INFORMANT'S MAILING ADDRESS : 596 CHEROKEE ROAD, LAKE FOREST, ILLINOIS, UNITED
STATES 60045
PLACE OF DEATH : ASPEN SUITES CITY OR TOWNSHIP : ROCHESTER
FACILITY NAME/ADDRESS : STATE AND ZIP CODE : MINNESOTA 55902
211 2ND STREET SW, ROCHESTER, MINNESOTA, UNITED STATES 55902 COUNTY OF DEATH : OLMSTED
METHOD OF DISPOSITION : Cremation CREMATORY NAME : OTHER
CREMATORY CITY, STATE : ROCHESTER MINNESOTA
CEMETERY NAME : CREMATION AUTHORIZER NAME: ROBERT REICHARD
CEMETERY CITY, STATE : CREMATION AUTHORIZER LICENSE NUMBER : 54754
FUNERAL HOME NAME : ROCHESTER CREMATION SERVICES FUNERAL HOME LICENSE NUMBER : 1056
FUNERAL HOME ADDRESS : 1605 CIVIC CENTER DR NW ROCHESTER MINNESOTA 55901 FUNERAL DIRECTOR : MICHAEL D JOHNSON
MEDICAL CERTIFIER NAME : ROBERT REICHARD DATE OF DEATH AND TYPE (MODIFIER) : May 14, 2017 ACTUAL DATE OF DEATH
TITLE OF CERTIFIER : M.E. TIME OF DEATH : 13:17 24 Hour
LICENSE NUMBER : 54754 TIME OF DEATH TYPE (MODIFIER) : ACTUAL TIME OF DEATH
MEDICAL CERTIFIER ADDRESS 200 1ST ST, ROCHESTER, MINNESOTA, UNITED STATES 55905 MEDICAL EXAMINER CONTACTED : Y
AND ZIP CODE :
DATE CERTIFIED : June 16, 2017
CAUSE OF DEATH LINE A : ASPHYXIATION DUE TO DISPLACEMENT OF OXYGEN IN CONFINED SPACE WITH HELIUM INTERVAL:
CAUSE OF DEATH LINE B : INTERVAL :
CAUSE OF DEATH LINE C : INTERVAL :
CAUSE OF DEATH LINE D : INTERVAL :
OTHER CONTRIBUTING CONDITIONS : AUTOPSY PERFORMED ? Yes
IF FEMALE, PREGNANCY INFO :
AUTOPSY FINDINGS AVAILABLE TO Yes
DID TOBACCO USE CONTRIBUTE TO DEATH : U
COMPLETE CAUSE OF DEATH?
ACME ICD CODES (ICD 1-20) :
MANNER OF DEATH : SUICIDE
ACME UNDERLYING CAUSE CODE :
INJURY OCCURRED ? : Yes PLACE OF INJURY: HOTEL/MOTEL
DATE OF INJURY : May 14, 2017 LOCATION OF INJURY : ASPEN HOTEL 211 2ND ROCHESTER MINNESOTA UNITED STATES 55902
TIME OF INJURY : STREET SW #316
INJURY AT WORK ?: N
IF TRANSPORTATION INJURY, NA
DESCRIBE HOW INJURY OCCURRED : PLACED BAG OVER HEAD AND ATTACHED HELIUM SOURCE
PLEASE SPECIFY: