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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN,.SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA Q��Af�T Y11'�'O� HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA� R �' fl� +��,�,^, s ��
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<br />DATE OF ISSUANCE �:7' � � �� " '
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<br />01/02/2009 ASS1��4NT SN��A7� REGLST24R ;; -
<br />DEP�If��lE1VT�0F:�lE/��7'l�AND. _ �;
<br />LINCOLN, NEBRASKA HUMAf�°,��RVICE� � ` .� ' -
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIGE�- ''. `4"A -` t r~. �� OS OO4SO
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<br />�.�r���rwH��vrur.�►�n , •_�, .,�.
<br />1. DECEDENT'S•NAME (First, Mlddie, Last, Suftbc) 2. SIX : f, �!3.�DATE OF DEAtF1 jNfo., Day, Yr.)
<br />Frank Ramirez Rivera Sr Male `` April �16,;�008
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Blrthday b. UNDER 1 YEAR Sc. UNDER 1 DAY B. DATE OF BIRTH (Mo„ Day, Yr.)
<br />(Y�•) MOS. DAYS HOURS NUNS.
<br />McAlester, Oklahoma 89 April 15, 1919
<br />7. SOCULL SECURITY NUMBER 8a. PLACE OF DEATH
<br />508 OSH pITAL � inpatleM OTHER ❑ Nursing Home/LTC � Hosplce Faellily
<br />Sb. FACILITY•NAME (Ii not Institut►on, glve etreet a�M number) � ERfOutpaHent ❑ DecedenYe Home
<br />K
<br />� Mary Lanning Memorial Hospital ❑ ooa ❑ Othar (SpecHy)
<br />� Bc. CITY OR TOWN OF DEATH pnclude ilp Code) Bd. COUNTY OF DEATH
<br />o Hastings 68901 Adams
<br />� 8a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />� 9d. STREET AND NUMBER 9e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIANTS
<br />�, 621 N. Pine St. 68801 � res ❑ nto
<br />� 70a. MARRAL STATUS AT TIME OF DEATH � Marrled ❑ Never Mlarrled 10b. NAME OF SPOUSE (First, Middle, Last, Suftfx) H wHe, give maiden �me
<br />� ❑ Marr►ea, nu� seParaced ❑ undowed ❑ nNorced ❑ unknown Mary Rebecca Aldana
<br />� 11. FATHER'S-NAME (Fhst, Middle, Last, Suffix) 12. MOTHER'S-NAME (Flrst, Mlddle, Malden Sur�me)
<br />m Joe Rivera Pauline Ramirez
<br />a 13. EVER IN US. ARMED FORCES9 Oive dat� oT aerWce ff Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />s (Yes, No, or unk.) Yes 08/18/1941-12/11/1945 Frdnk Rivera Jr Son
<br />,g 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 76b. UCENSE NO. 18c. DATE (Mo, Day, Yr.)
<br />F � Burial ❑ DonaUon
<br />Kevin Wood 1325 April 29, 2008
<br />❑ CremaUon ❑ Errtombment 18d. CEMETERY, CREMU►TORY OR OTHER LOCATION CffY / TOWN STATE
<br />❑ Removal ❑ Other (Specity)
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (3treet, Cily or Town, State) 17b. Zlp Coda
<br />Uvtngston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br />CA SE OF DEATH See instructlons and exam les
<br />18. PART L EMer the ahaln oT eva�--0laeasea, �nJurles, or complleaGone-that d(recty cauaed Ure death. DO NOT e�rter terMnal events euch as caNlae erteat, ` APPROJOMATE INTERVAL
<br />resptratory erraet, orventricular flbHilatlon wRhout showing the edotogy. DO NOT ABBREYIATE E�Rer onty o�re wuae on a Me. Atld adeWonalli�res H ne�swry.
<br />IMMEDIATE CAUSE: ; onset to death
<br />immeow�recause��at eIRENAL FAILURE ; 2 WEEKS
<br />disea� or conditlon resulUng
<br />�� ��'� DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />SequeMlalty Itst condMlona, M b)
<br />enY. �ead�n8 M the raauae Ilsted �
<br />on Wre a DUE TO, OR AS A CONSEQUENCE OF: 0 o�et to death
<br />Frrter the UNDERLYINO CAUSE C � �
<br />(disease Or InJury t�at iniqatetl . i
<br />� B" �� �" d�'� DUE TO, OR AS A CONSEQUENCE OF: � onset to death
<br />� d) �
<br />18. PART p. OTHER SIONIFlCANT CONDffIONS-Comlltions coMributing W the death but rrot �ulUng In the underiytng puse given in PART I. 18. WAS MEDICAL EXAMINER
<br />GASTROINTESTINAL BLEEDING OR CORONER CONTAC7ED4
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 27a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORIV�D?
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<br />� � Noi pre9nant wtthin P� Y� �� p Ho�uaaa 0 oa�.ro
<br />v ❑ a�� � s� m a�sn � n�iaeM � Pending ImreaUBadon ❑ a�ne�• ❑ ves � No
<br />� � Not pregnant, but pregnant rkhin 42 dsys af death � PedesLrian 21d. WERE AUTOPSY FlNDINGS AVAILABL
<br />a � Not pregnaM, bu! pregnaM 49 daye to 1 year before death �$"�dae � Coultl nM be tletermined ❑ � r 15�� TO COMPLETE CAUSE OF DEATH?
<br />� ❑ Un�mown H pregnant wlthln the past year ❑ 1IE3 ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY•At home, fann, street, taetory, oftice bullding, cor�truetlon atte, etc. (Specity)
<br />E
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<br />� 22d. INJURY AT WORK4 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />� ❑ v�s ❑ No
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYROWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIONED (470., Day, Yr.) 24b_TIME OF DEATH
<br />� � April 16, 2008 � � �
<br />�-� 23b. DATE SIGNED (Mo., Day, Yr.) 23e. TIME OF DEATH ���� 24c. PRONOUNCED DEAD (Mo., Day, Yr.� 24d. TIME PRONOUNCED DEAD
<br />E� Z A ril 17, 2008 08:50 AM � d< z
<br />$�� To the bea[ of my btorleEga, death oceurred at the time, dete and plaee $��� 24e. On the basis of exeminadon anNOr inveadgatlon, in rtry opinlon death ocwrred at
<br />$� ana aue eo ure eause�s� smcea. �sienaeure ana nue) � o � ure ume. aaie a� W a e e ana due ro me cause(s� emcea. (st¢neuue ana ruie�
<br />~ Justln Wenburg, MD ~ � a
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH9 28a. HAS ORGAN OR TISSUE DONATIOPI BEEN CONSIDERED? 26b. WAS CONSENT (iRANTEDT
<br />❑ YES ❑ NO ❑ PROBABLY � UNIdVOWN � YES ❑ NO Not Appiicable H 28a Is NO ❑ YES � NO
<br />27. E, TITLE D DRESS O C IFI (P SI R N R HYSI O CO NTY A RN (Type or Print)
<br />Justln Wenburg, MD, 2115 N Kansas Avenue, HasUngs, Nebraska, 68901
<br />2Ba. REGISTRAR'3 SIGNATURE /R • � 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />�� April 23, 2008
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