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To be completed/verified by: FUNERAL DIRECTOR I 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) Jennifer Lynn Martinez 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) March 7, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 5a. AGE • Last Birthday (Yrs.) 57 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) December 16, 1955 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 505 -78 -9105 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Saint Francis Medical Center ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 816 East Sunset Avenue 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Richard Martinez 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ralph Poppert 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Janice Hausmann 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Richard Martinez 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION IX1 Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Daniel D Naranjo 16b. LICENSE NO. 1071 16c. DATE (Mo., Day, Yr.) March 13, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) I To be completed by: CERTIFIER 18. PART I. Enter the chain of events- - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Days respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute Renal Failure disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Metastatic Breast Cancer To Bone, Liver with ascites, and Pleural Space 3 Years any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I. Hypertension 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: ® Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident El Pending Investigation ❑ Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office building, 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE k W E N 6 23a. DATE OF DEATH (Mo., Day, Yr.) March 7, 2013 j; gi i E < J E O $ w z 8 C R rs § ; 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) March 18, 2013 23c. TIME OF DEATH I 06:15 PM 24 PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the best of $ knowledge, death occurred at the time, date and place my P 2 and due to the cause(s) stated. (Signature and Title) a Kimberly A. Mickels, MD Yoe• On the basis of examination and/or Investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 126a. REGISTRAR'S SIGNATURE /j �J� Mr A - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 19, 2013 STATE OF NEBRASKA 201302424 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTRAN04.043 SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEPRASKAPEEEAR r 7 OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY-FOR VITAL FDS.• DATE OF ISSUANCE "r,rSTANLEY S. COOPER ASSISTANT STATE RSI'S ! ASSISTANT LINCOLN, NEBRASKA 03/21/2013 NIUAfiA�I STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV1)CES CERTIFICATE OF DEATH 13 01195