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STATE OF NEBRASKA WHEN THIS COPY CARRIES ) nC RAISED SEAL OF THE NEBRASKA DEPARTMEN I OF HEALJ1'►`A /D HthtfAN:SOMCES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OFfilF.ALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORD 1 DATE OF ISSUANCE STANLEY S. COOPER 201308811 ASSISTANT ST REGISTRAR DEPARTMENT OAF HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES 07/02/2012 STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 12 02331 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Jose Luis Espinoza 2. SEX Male 3MATE OF DEATH (Mo., Day, Yr.) June 29, 2012 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Mexico 5a. AGE - Last Birthday (Yrs.) 37 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) August 24, 1974 Mpg, I DAYS HOURS l MINS. 7. SOCIAL SECURITY NUMBER 506 -37 -5061 8b. FACILITY-NAME (If not Institution, give street and number) 1014 N. Beal 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (IncLide Zip Code) Grand Island 68801 3d. COUNTY OF DEATH Hall 9a. RESIDENCE-STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1014 N. Beal 19e. APT. NO. 9f. ZIP CODE I 68801 I 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Lisa Marie Casares 11. FATHER'S•NAME (First, Middle, Last, Suffix) Juan Espinoza Ortiz 12. MOTHER'S -NAME (First, Middle, Malden Surname) Petra Ramirez Martinez 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT-NAME Lisa Marie Espinoza 14b. RELATIONSHIP TO DECEDENT Spouse 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.) June 29, 2012 15d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon 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) 15. PART 1. Enter the Ebain of events. - diseases, injuries, or compllcations4hat 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) Metastatic Renal Cancer Months disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, if b) 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 N. OTHER SIGNIFICANT CONDITIONS-Condltions contributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES Ed 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 Dll 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 Ej NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. 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 L'1 i l ‘' z 23a. DATE OF DEATH (Mo., Day, Yr.) June29,2012 p B Y k < B § ` o` o 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) June 29, 2012 123c. TIME OF DEATH 12:01 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 . To the hest of my knowledge, death occurred at the time, date and oleos .8 . and due to the cause(*) stated. (Signature and Title) ' I Sara Graybill, MD 34e. On the barb Of examination andlor Investigation, in my opinion death occurred at the tine, date and plan and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN 288. HAS ORGAN OR TISSUE DONATION ❑ YES ® NO BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, FHYStCIAN Sara Graybill, MD, 2116 W Faidley #400, Box 9802, ASSISTANT, CORONER'S OR COUNTY A Grand Island, Nebraska, 68803 ORNEY) (Type or Print) 28a. REGISTRAR'S SIGNATURE /j i C A'. 28b. DATE FILED BY REGISTRAR ( Da Yr. I July 2, 2012 STATE OF NEBRASKA WHEN THIS COPY CARRIES ) nC RAISED SEAL OF THE NEBRASKA DEPARTMEN I OF HEALJ1'►`A /D HthtfAN:SOMCES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OFfilF.ALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORD 1 DATE OF ISSUANCE STANLEY S. COOPER 201308811 ASSISTANT ST REGISTRAR DEPARTMENT OAF HEALTH AND LINCOLN, NEBRASKA HUMAN SERVICES 07/02/2012 STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 12 02331