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1. DECEDENT - NAME FIRST MIDDLE LAST - Daniel Patrick Monroy 2. SEX Male 3. 13RTE OF DEATH (Month. Day. Year) ;June 13, 2003 4. CITY AND STATE OF BIRTH Ill not in U.S.A.. name country) San Antonio, Texas 5a. AGE - Last Birthday (Yrs.) 62 UNDER 1 YEAR UNDER 1 DAY 6. DATEeDF BIRTH (Month Day. Year) March 17, 1941 5b. MOS. I DAYS 5c. HOURS' MINS. 7. SOCIAL SECURTIY NUMBER 389 -36 -5849 8a. PLACE OF DEATH H OSPITAL: Inpatient OTHER: - ❑ ❑ ❑ ER Outpatient ra [] DOA • Nursing Home Residence • Other (Specdvr 8b. FACILITY - Name /ff not institution, give street and number) 4026 Edna Drive 8c. CITY. TOWN OR LOCATION OF DEATH Grand Island 8d. INSIDE CITY LIMITS Yes {] No ❑ 8e. COUNTY OF DEATH Hall 9a RESIDENCE - STATE Nebraska 9b. COUNTY Hall 9c. CITY. TOWN OR LOCATION Grand Island 9d. STREET AND NUMBER (Including Zip Code) 4026 Edna Drive 9e. INSIDE CITY LIMITS Yes i No ■ 10. RACE - (e.g., White. Black. American Indian. etc.) (Specify) American 11, ANCESTRY (e.g.. Italian, Mexican, German, etc) (Sped) ` Mexican 12. FA MARRIED ❑ WIDOWED ❑ NEVER pi DIVORCED 13. NAME OF SPOUSE /d wife. give maiden name) Carrie Difatta (Specify only highest grade completed) 14a. USUAL OCCUPATION (Give Meld work done during most of working file, even if retired) Information Security Officer MARRIED 14b. KIND OF BUSINESS INDUSTRY Veterans Administration 15. EDUCATION Elementary or Secondary 10 -12) Colleue 11-4 or 5 I 12 JS 16. FATHER - NAME FIRST MIDDLE LAST Jaime Monro 17. MOTHER FIRST MIDDLE MAIDEN SURNAME Josephine Martinez 18. WAS DECEASED EVER IN U.S. ARMED FORCES? (Yes. no. or unk.) (If yes. give war and dates of r v ic e // 22 // 9 Yes: Vietnam War: ':10 loh INFORMANT ueu wr_ ennoccc 9a INFORMANT -NAME Carrie Monroy 23. IMMEDIATE CAUSE PART I W Cardiac arrest (bl (c) 32a. REGISTRAR WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILEWITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 6/27/2003 LINCOLN, NEBRASKA 4026 Edna Drive, DUE TO, OR AS A CONSEOUENCE OF DUE TO. OR AS A CONSEQUENCE OF: 201309451 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT - _- VITAL STATISTICS 03 CERTIFICATE OF DEATH ISTR OR R NO., Li! OR TOWN. STATE. ZIP) Grand Island, Nebraska 68801 (ENTER ONLY ONE CAUSE PER LINE FOR Ial. Ibl. AND (cp St ANLEY S. COOPER -- ASSISTANT STATEREGRAR HEALTH AND HUMAN SERVICES SYSTEM 20. EMBALMER - SIGNATURE 8 LICENSE NO. 22a. FUNERAL H - NAME Apfel - Butler- Geddes 21a METHOD OF DISPOSITION Burial ❑ Removal ❑ Cremation ❑ Donation 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 1123 West Second, Grand Island, NE. 68801 21b. DATE June 18, 2003 21c. CEMETERY OR CREMATORY NAME Ft. McPherson National 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Maxwell, Nebraska 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type or Print) Sgt D Dubbs, GIPD, 131 S Locust, !rand Island, NE 68801 NTED? YES 07139 Interval between onset and death immediate Interval between onset and death Interval between onset and death PART OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related II 26a. • Accident El Undetermined • Suicide El Pending E Homicide Investigation 26b. DATE OF INJURY (Mo.. Day. Yr.) 26e. INJURY AT WORK Yes ❑ No ❑ 27a. DATE OF DEATH (Mo.. Day. Yr.) 27b. DATE SIGNED (Mo.. Day. Yr) 27c, TIME OF DEATH 27d. To the best of my knowledge. death occurred at the time, date and place d M causelsl stated. I (Signature and Title) II. M 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? El YES El NO 13 UNKNOWN 26c. HOUR OF INJURY M 261. of building etc %S it)r) farm, street factory PART III IF FEMALE. WAS THERE A PREGNANCY IN THE PAST 3 MONTHS? I I (Ages 10 -54) Yes No L I 26d. DESCRIBE HOW INJURY OCCURRED MTO o • U 26g. LOCATION ace an due to a 28e. On the bas the time,d (Signatu 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSID ❑ YES NO 28a DATE SIGNED (Mo.. Day. Yr.) 26c. PRONOUNCED DEAD (Mo.. Day, Ys) 24 AUTOPSY Yes I I No STREET OR R.F.D. NO. 28b. 28d. ination and IOd due t in 25, WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? Yes al No n CITY OR TOWN STATE TIME OF DEATH 9:30 pm PRONOUNCED DEAD (Hourl 10:51 pm nion death occurred at at NO 32b. DATE FILED BY REGISTRAR /Mo., Day. Yr.) 2003 M