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DATE OF ISSUANCE 05/22/2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH 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 VITALRECdRDS.;, STANLEY ,-COOP : . L" , 2 01308772 DES 7MEAT LTHAND' LINCOLN, NEBRASKA P(UUMAN SERVICES T i T STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERNf(rES • CERTIFICATE OF DEATH ', ,t' `.-;, _•` 3 02194 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Diego Gerardo Reyes 2. SEX cam `.' L • Male e „ °.. , kg fUTE"bF'D�! �((Mb., Day, Yr.) - ,May 1,5,'2 )1& 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Mexico 5a. AGE - Last Birthday MO 44 5b. UNDER 1 YEAR 5c. UNDER 113AY •6: DATE �QF BIRTH (Mo., Day, Yr.) • November 13, 1968 MOS. , DAYS HOURS MINS. ( 7. SOCIAL SECURITY NUMBER 506-23 -1126 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) Grand Island 68803 1 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall Sc. CITY OR TOWN Grand Island 9d. STREET AND NUMBER e. APT. NO. 4012 West Faidley r I 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS I I YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Veronica Paramo 11. FATHER'S -NAME (First, Middle, Last, Suffix) Nicolas Reyes 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Sabina Camargo 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Veronica Reyes 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER-SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) May 21, 2013 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / 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) 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 4 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) Anoxic Encephalopathy disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death sequentially list conditions, if b)Asphyxiation 4 Days 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 tints of deaM ❑ 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) (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO construction site, etc. (Specify) 22a. DATE OF INJURY (Mo., Day, Yr.) May 13, 2013 22b. TIME OF INJURY 09:00 AM 22c. PLACE OF INJURY At home, Home farm, stmt, factory, office building, 22d. INJURY AT WORK? ❑ YES El NO 22e. DESCRIBE HOW INJURY OCCURRED Hanging 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE Unknown, Grand Island Nebraska 68801 .6'S I t >. 16 I 23a. DATE OF DEATH (Mo., Day, Yr.) May 15,2013 $ g 1 g 0 € % < $ te & g 3 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) May 17, 2013 23c. TIME OF DEATH I 06:45 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 30. To the best of my knowledge, death occurred at the time, date and place o and due to the cause(s) stated. (Signature and Title) David R. Colan, MD 24e. On the basis of examination and/or investigation, in my opinion death Occurred at the time, data and place and due to the cause(s) stated. (Signature and Tale) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES ❑ NO 260. WAS CONSENT GRANTED? Not Applicable If 26a is NO ® YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 I28a. REGISTRAR'S SIGNATURE /JET /��►�('�� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I May 20, 2013 DATE OF ISSUANCE 05/22/2013 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH 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 VITALRECdRDS.;, STANLEY ,-COOP : . L" , 2 01308772 DES 7MEAT LTHAND' LINCOLN, NEBRASKA P(UUMAN SERVICES T i T STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERNf(rES • CERTIFICATE OF DEATH ', ,t' `.-;, _•` 3 02194