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To be completed by: CERTIFIER I l To be completed/verified by: FUNERAL DIRECTOR 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Sisto G Rangel 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) February 23, 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lexington, Nebraska 5a. AGE • Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) (Yr3.) 68 MOS. DAYS HOURS MINS. February 19, 1945 7. SOCIAL SECURITY NUMBER 507 -52 -9069 8b. FACILITY -NAME (If not Institution, give street and number) Nebraska Heart Hospital 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68526 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8d. COUNTY OF DEATH Lancaster 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 4122 Prairie Ridge Lane 9e. APT. NO. 9f. ZIP CODE 1 I 68803 LI 9g. INSIDE CITY MITS I YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH D Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Diane Dyke 11. FATHER'S -NAME (First, Middle, Last, Suffix) Sixto Rangel 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Lupe Ceballos 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or link.) No 14a. INFORMANT•NAME Diane Rangel 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) February 25, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Aspen Cremation Service Lincoln Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Aspen Aftercare Cremation & Burial Service, Inc., 4822 Cleveland Ave., Lincoln, Nebraska 17b. Zip Code 68504 CAUSE OF DEATH (See instructions and examples) 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 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: onset to death IMMEDIATE CAUSE (Final a) Anoxic Encephalopathy 9 Days disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Operative Repair Of Aortic. Arch Aneurysm 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. 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 ❑ Pending Investigation ❑ Suicide ❑ 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 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 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 1 t Y I- 6 z 23a. DATE OF DEATH (Mo., Day, Yr.) February 23, 2013 k 5 i i k ,. a. < c W .8 C 6 ~ s 24a. DATE SIGNED (Mo.. Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24b. TIME OF DEATH 24d. TIME PRONOUNCED DEAD 23b. DATE SIGNED (Mo., Day, Yr.) February 25, 2013 23c. TIME OF DEATH I 09:40 PM s 44 0 9d. To the best of my knowledge, death occurred at the time, date and place o c and due to the cause(s) stated. (Signature nd Title) 2 R. Kent Jex, MD 24e. 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? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ❑ NO ❑ PROBABLY tEl UNKNOWN ® YES ❑ NO _ 26b. WAS CONSENT GRANTED? Not Applicable If 26a Is NO ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OFCERTIFIER (Type or Print R. Kent Jex, MD, 7440 S 91st St, Lincoln, Nebraska, 68526 P I28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 25, 2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF AND, HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS_ DATE OF ISSUANCE 02/26/2013 LINCOLN, NEBRASKA 201302935 STANLEY ST COOPER. ASSISTANT $TATE`-REGISTRAR DEPARTMENTCF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES , CERTIFICATE OF DEATH 13 00832