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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 VITA!, ECORDS. ° '9 DATE OF ISSUANCE 09/03/2013 LINCOLN, NEBRASKA STATE OF NEBRASKA 201309543 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH • STANLEY S. COOPE ASSISTANT STATE EGISTRAR- DEPARTMENT OF HEALTH ANO HUMAN SERVICES 13 03713 1. DECEDENTS-NAME (First, Middle, Last, Suffix) Gonzalo Luevano -Salas 2. SE)( Male - 3..DATE OF DE. IR (Mo., Day, Yr.) = August 23; 2013 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Mexico 5a. AGE - Last Birthday (Yrs.) 60 5b. UNDER 1 YEAR 5c. UNDER i DAY ,6.-DATE-OF BIRTH (Mo., Day, Yr.) January 10, 1953 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 507 -78 -8212 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 El 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 904 West North Front Street e. APT. NO. r 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 Rosa Martinez 11. FATHER'S -NAME (First, Middle, Last, Suffix) Esteban Luevano Flores 12. MOTHER'S•NAME (First, Middle, Maiden Surname) Mercedes Salas Cruz 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Rosa Luevano 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) August 26, 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) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART 1. Enter the chain of events -- diseases, Injuries, or complicatlons•that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL onset to death Minutes 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) Myocardial Infarction disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially list conditions, If b) Hypertension 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. 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 ❑ AccldeM ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger El Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 3 N 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 0 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE B W O la j E z E. 23a. DATE OF DEATH (Mo., Day, Yr.) .2, § I e i J E N Z z 8 W 0 2 z p '" o O 24a. DATE SIGNED (Mo., Day, Yr.) August 28, 2013 24b. TIME OF DEATH 01:50 AM 23b. DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) August 23, 2013 24d. TIME PRONOUNCED DEAD 01:50 AM 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 c and due to the cause(s) stated. (Signature nd Title) f 24e. On the basis of examination and/or investigation, In my opinion death occurred at the time, date and place and due to the causes) stated. (Signature and Title) e Nancy Berger- Schneider, Hall Deputy County Attorney 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 H 26a Is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Nancy Berger- Schneider, Hall Deputy County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 1 28a . REGISTRAR'S SIGNATURE A - 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I Aug ust 30, 2013 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 VITA!, ECORDS. ° '9 DATE OF ISSUANCE 09/03/2013 LINCOLN, NEBRASKA STATE OF NEBRASKA 201309543 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH • STANLEY S. COOPE ASSISTANT STATE EGISTRAR- DEPARTMENT OF HEALTH ANO HUMAN SERVICES 13 03713