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To Be CompletedNerified by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix) -
<br />Ana Maria Sanchez
<br />2. SEX
<br />Female
<br />3. DATE•CF ElEATH (Mo.,Day,Yr.)
<br />February 15, 2013
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Mexico
<br />6a. AGE -Last Birthday
<br />(Yrs.)
<br />69
<br />6b. UNDER 1 YEAR
<br />6c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />December 1, 1943
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />_ _ 3 5 9 - 9 8 - 4 8 9 8
<br />8a. PLACE OF DEATH
<br />HOSPITAL © Inpatient QTHER: 0 Nursing Home/LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />0 DOA 0 Other(Specify)
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />8c. CITY OR TOWN OF DEATH (Include Zlp Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1824 West 5th Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />E Yea ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH IE Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OP SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
<br />Jesus Sanchez
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Alejandro Alejandre
<br />12.1VIOTHER'S -NAME (First, Middle, Maiden Sumame)
<br />Maria Luisa Espinoza
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) N
<br />14a. INFORMANT -NAME
<br />Jesus Sanchez
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />amnia! phonation
<br />❑Cremation ❑Entombment
<br />3 temovel ❑Othery8peclty)
<br />ER -$I A E
<br />R
<br />fit v J5 �(% J
<br />18b. LICENSE NO.
<br />/ 7/
<br />16c. DATE (Mo., Day, Yr.)
<br />March 5, 2013
<br />16d. CEMETERY, CREMATORY OR OTHER L ATION CITY/TOWN STATE
<br />Funerales Calzada Sahvayo Mexico
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />1 C—� / To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />15. PART I. Enter the chain of event' - diseases, Nudes, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />respiratory arrest, or vernacular Bbrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause eh a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final r i v
<br />disease or condition resulting a) `
<br />In death)
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially leading to the cause listed b)
<br />an - ► - _ y, ding to e use lise L4j.
<br />on Ilne a. DUE TO, OR AS A CONSE ENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or In)ury that Initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF onset to death
<br />LAST
<br />d)
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES or NO
<br />20. IF FEMALE:
<br />C; of pregnant within past year
<br />❑ Pregnant at time of death
<br />Not pregnant, but pregnant
<br />❑ p g t, p gnant within 42 days of death
<br />❑Not pregnant, but pregnant 43 days to 1 year before death
<br />['Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />'Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrlan
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES jg
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />m
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />DYES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) Z
<br />X
<br />> i 5 1)
<br />aW
<br />W
<br />aV
<br />a O Z
<br />8 W Z
<br />2 O O
<br />F V O
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
<br />S IM Z 23b. DATE NED (j�o. Yr.)
<br />23c. TIME F D�TH, m
<br />24 PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD m
<br />m o 23d �s • j knowledge,
<br />o W e cause
<br />F- ' .
<br />• =tit oc : d at the time, data and place
<br />ts :.. Signet s Tine)
<br />� # . �/
<br />24e. On the basis of examination andlor Investigation, in my opinion death occurred
<br />use(s) stated. (Signature and Title)
<br />at the time, date and place and due to the cause(s)
<br />25. DI. OBACCO USE CONTRI
<br />YES ❑ NO ❑ PROS
<br />T TO E D TH?
<br />: LY UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />rES ❑ NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO , YES ❑ NO
<br />7. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Dr. Joshua Anderson, 908 N. Howard, Grand Island, NE 68803
<br />P
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAR 4 2013
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE4ft H P D H SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE N CEPAR,TMEtVT 1F HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR ITA'l11r T2QR S. mss., t 1
<br />r.
<br />DATE OF ISSUANCE
<br />MAR 0 4 2013
<br />LINCOLN, NE
<br />ST.QNL o : l r
<br />' A SISTA G STRAR'
<br />MARTMEUT H ALTfi NC
<br />NEBRASKA
<br />HUMAN RV tk ,', q{r • • r :, ,.
<br />', Ar OFirl'' A
<br />STATE OF NEBRASKA_ DEPARTMENT OF HEALTH AND HUMAN SERVI " !� ' "
<br />201301744
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