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1 t DECEDENT - NAME FRS? MOLE - LAS? <br />Teresa P. Noriega <br />2 SEX 3 DATE OP DEATH ,Moen Dar V.R1 <br />Female IMarch 20. 2004 <br />s CITY AND STATE OF BRTH reroroUSA A <br />Sutherland, Nebrask <br />5a AGE LA EB SIAIy <br />Y "' 76 <br />UNDER t YEAR <br />UNDER / DAY 6 DATE OF BATH 'WNW W\ read <br />5E NOS 1 °�� <br />SC S Oc #obey 15, 1927 <br />7 SOCIAL SECURTIY NUMBER <br />505 -44 -3947 <br />fa PLACE OF DEATH <br />HOSPITAL ❑ raeent OTHER = <br />a ER OWMeIe <br />0 DOA 11 <br />Nu sww Hone <br />Re6a0erlc. <br />a, Some <br />B3 n, <br />FACILITY - NM I .nOT /wl a1110R gl <br />St. Francis Skilled Care <br />AC CITY TQWNOR LOCATION OF DEATH <br />Grand Island <br />SAO INSIDE CITY UNITS <br />Yee [J No <br />se COUNTY OF DEATH <br />Hall <br />9a RESIDENCE - STATE (SO COUNTY <br />Nebraska I Hall <br />CA <br />9e CITY TOWN OR LOTION <br />Grand Island <br />90 STREET AND MASER •Inc agi19ZEI Codes 1 9e INSIDE CITY LASTS <br />614 B. DivIsita St. 68801 Yes 1•=• wo • <br />10 R1.CE • is. :. Were Bnca Amenca t X1 � 1 It. ANCESTRY leg . Mescal. German. mc• <br />01C.11SoeC+yl �a n ISpet_ . 171 <br />j — <br />12. ■ MARRIED 0 WIDOWED <br />NEVER DIvORCED <br />t3 NAME O J/ e ca <br />F SPOUSE 0 wwase" Paw/ <br />m <br />M ❑ <br />vebeb,workOwedumgmest <br />tea d SUALOCGMAWATION 1G .F9n e /aR/aa t <br />s l 6019 <br />Hair Stylist <br />tab KIN D OS BUSIMESSINDUSTRY IS EDUCATION ISRBCdyaeYtgeaRggaecompefe9: <br />Ha Salon eL 12 s.eaea,D -tz, 21 -S0e -a <br />16 FATHER - NAME FIRST MIDDLE LAST . 1 IT MOTHER FIRST MIDDLE MAIDEN SURNAME <br />I Patricio Noriega I Anita Veneoas <br />18 WAS DECEASED <br />P Yes nO. a unkj <br />No 1 <br />EVER IN US ARMED FORCES? ' 19a IHFORMMIT - NAME <br />+ IM yes aye pm OW dales d semcwe <br />- Josephine Romero <br />190 INFORMANT MAILING ADDRESS ISTREET OR R 0 NO.. CITY OR TOWN STATE BPI <br />123 N. Locust St., Apt. 703. Grand, Nebraska 68801 <br />20 E■BALMER- U aL NO . <br />9 . 144,8d 91071 <br />21a METH000F DIPOST'ON <br />®BIFw • Remcaal <br />21b DATE <br />Id i 24. <br />21c CEMETERY OR CREMATORY NAME <br />i1lestlas: M _ Pak Ceoatery <br />22a FUNERAL HOME • NAME <br />All Faiths Funeral Home . <br />El Dormice DDonale <br />217 CEMETERY OR CREMATORY LOCATION CITY OP TOWN STATE <br />1 Grand Island, Nebraska <br />223 FUNERAL HONE ADDRESS (STREET OR RE C.. NO. CITY OR TOWN STATE. DPI <br />2929 S. Locust St., Grand Island, Nebraska 68801 <br />23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR IN M. AND loll a,MYal between sleet 150 0 <br />PART <br />lal �, ♦ - # O A %. wt." 0= _ Nana • � �O `� �. <br />DUE TO. OR AS A CONSEQUENCE '_ OOFF every. onset an near <br />le DUE <br />kt � , 1 l <br />TO. OR AS A CONSEQUENCE OF I bleeen onset ane ceaa <br />I:i <br />PAR, OTHER SIGNIFICANT CONDITIONS . MS c Aing ID Re alma as np mimeo THAW al IF FEMALE WAS THERE A ' 24 AU 1 25 TOPSY t WAS LASE REFERRED T MEDICAL <br />L ,J(w/�e Ve l \ ` l PRE GNANCY IN THE PEST 3 MONTHS' EX oR C ORONE R ` <br />A Q� � r �t�' _ � I (mss 10.54$ Yes • 40 Eh vN n No [1E � i Yes n No fj <br />26a <br />❑ Accleele 0 Umbewmvneo <br />M BI Shope PesO'^4 <br />M HomCde meee59wo' <br />263 DATE OF INJURY /AM De YW.) <br />26s HOUR OF INJURY 1 <br />M <br />260 DESCRIBE HOW INJURY OCCURRED <br />26e INJURY AT WORK <br />Yes [J No <br />hone <br />26t �NJURY ,A1 . street %ORR <br />SOae17Y1 latm <br />263 LOCATION STREET OR RFD NO CITY OR TOWN STATE <br />$g <br />3$ <br />I� <br />27a DATE OF DEATH No Oar W I <br />March 20, 2004 <br />3 + <br />€ 1 a <br />28a DATE SIGNED rµ1 Dar V <br />260 TIME OF DEATH <br />DATE SIGNED !M3 Dav wr, a 12 7c TIME OF DEATH <br />- a4-w 07:05 A. M <br />tar PRONOUNCED DEAD aMb UMW. vrt <br />260 PRONOUNCED DEAD Hap <br />M <br />270 Tome batalnN MMwNOga . ..: � .. .. <br />Weral <br />6a Ostia <br />I... 4♦► _ _ . L.I <br />29 DID TOBACCO U 4.,!.. -1,11 1 -0-4L . - .I " a a HAS ORGAN OR TISSUE DONATION <br />YES 01 NO . UNKNOWN I in YES <br />° � 2M On me OaRi Otasa+wlaaM <br />_ - I em <br />le e drse and piece we <br />I .. And Tie <br />BEEN SIDERED' <br />NO <br />tga <br />anYasegaPOn. mtny won warn «cut110 a1 <br />we w Ole Meets! staled <br />300 WAS CONSENT GRANTED' <br />0 YES NO <br />^^" <br />31 NAME AND ADDRESS • CE' _- IPHYSICIAR, CORONERS PHYSICIAN OR COUNTY ATTORNEY. . Tew°, P.m/ <br />Klaiber]. A. Nickels M.D 729 N. C star Ave. Grand Island NE 8803 <br />32a RFINRTRAR <br />7 <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT Of-HEAL <br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE WIGINAL RECp <br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,, VITAL RECORDS <br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. . <br />DATE OF ISSUANCE <br />AUG 21 2013 <br />LINCOLN, NEBRASKA <br />STATE OF NEBRASKA <br />SP}WLEY CI OOP (2 <br />a45 1 S7AN3 ' 7 1 REGI TRAR <br />'QEPPRTMENT OF HE AND -; <br />W yMAM..9MVICES <br />STALE OF NEBRASKA- DEPARTMENT OF HEALTH MD HUMAN SERVICES FINANCE AS) r I 1 <br />VITAL STATISTICS 4 <br />201400092 <br />CERTIFICATE OF DEATH <br />32b DATE REED BY REGISTRAR /ere Dew WI <br />MAR 3 0 2004 <br />