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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTkL 4NCM4J144 V. SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA5kA EP4PTMENrOf HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITA RECORD$'.
<br />DATE OF ISSUANCE
<br />08/20/2013
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />0Houpas PlcIIIG
<br />1. DECEDENT'S:.NAME {FIG, Middle, Last, :Suffix)
<br />Eusebio Venegas Nor lege ; AKA Jerry Noriega
<br />4 CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hershey, Nebraska
<br />7, SOCIAL SECURITY NUMBER
<br />506 -46-01
<br />52
<br />FACILITY-NAME (y not tnWhMon, glys street end number) ..
<br />Mary Lanning Memorial Hospital
<br />Sc. CITY OR. TOWN OF DEATH (Include Zip Cade
<br />Hastings 68901
<br />RESIDENCE -STATE
<br />Nebras
<br />Id. STREET. AND NUMBER
<br />614 East Division
<br />re. :COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Marled RI Never Married 105. MANE OF SPOUSE (First, Mlidda, Last, Suffix) S wife, give maiden name.
<br />0 Married, bat separated D WldowW ❑ DIvorced 0 UMaown
<br />11.:FATHEIt'S.NAME (First Middle, Last Suffix)
<br />Patrice* Noriega
<br />13. EVER IN U.S. ARMED FORCES? Give dates of uce If Yes. 141. INFORMANT-NAME
<br />(Y No, or Unit.) No Josephine A Romero
<br />IM
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />Sequsndally Est caWlNonS b) tt
<br />.t Nadingtothimanikbd. We SJo
<br />on e ar : DUE TO, OR AS CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE a)
<br />(dhows of Injury that IME.ad
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />: onset to
<br />onset to death
<br />mast to death
<br />16. METHOD OF DISPOSITION
<br />Gam Eloonsuon
<br />Ocr.arnan Ositambnent
<br />Opmemut DothanaN■aunl
<br />17a. FUNERAL HOME NAME AND MAJUNGA DDRESS :(streN, city or : Sown State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instruct one and examples)
<br />ores.pxatl.,ntErlBiscay c1101d1w NOT solar Webs' meal.: ash as e.rdeS emit,
<br />the Melody. DO NOT ABBREVIATE Saar only one sows can. law. Add sddeWfd Ens' x nwary.
<br />M EDIATE CAUSE: sees.
<br />IMMEDIATE CAUSE (Final
<br />dNouss or condition resulting - a) y).p'Y,/ e I- -�
<br />In death)
<br />is. PART .EMMMS Ala damns
<br />MblwteN a feet, M VeMANMer
<br />ISa.
<br />18d. , CREMATORY OR OTHER LoeA
<br />Grand Island City Cemetery
<br />/Ktf
<br />18 PART IL OTHER SIGNIFICANT CONDITION+ Condldona contrlbasdng to the death but not resulting In the undet11ng cause given In - . .PARTY.
<br />Yr.) 1 22b. TIME
<br />221. LOCATION OF INJURY -STREET II NUMBER APT. NO.
<br />STATE
<br />20. IF FEMALE:
<br />pregnant MEd. past your
<br />© Pregnant at time of death
<br />D Not pregnant, but pregnant 42 days of death
<br />°Not regnant, but pregnant 43 days to 1'yar be ton Grath
<br />Ounarown If pregnant within Ire past year
<br />22s. DATE OF INJURY (No., Day
<br />g
<br />23.. DATE OF DEATH (Mo., Day, V .)
<br />C ;
<br />2ts:MAN OF DEATH
<br />CI ',Whim' O Homicide '.:.
<br />D Accident 0 Pending Invesagstion
<br />[] SuleW. DCould net be dNNmined
<br />235. DATE SIGNED (Moe, Day, Yr.) 3e TIME OF DEATH
<br />( JURY
<br />.?-I5—/ 3 1:,Zs am
<br />23d. To the beet of my knowledge, death occurred at the Ems, data and Macs
<br />and d the - a) stated. (Signature and TWO
<br />27, NAME, mI.E AND ADDRESS OF CERTIFIER (Type or Pant)
<br />Lorraine Edwards, M.D., 2727 W. 2nd St. ,Ste
<br />204 REGISTRAR'S SIGNATURE
<br />STATE OF NEBRASKA
<br />201400093
<br />lb. UNDER 1 YEAR
<br />MOS.
<br />OF
<br />71
<br />S. PLACE OF DEATH
<br />scrim : ® lepad•at
<br />Dom►
<br />Sc. CITY ORTOWN >.
<br />Grand island
<br />APT, No.
<br />Male
<br />MOTHER'S-NAME (First, Middle,
<br />Anita Venegas
<br />Sc. •
<br />UNDER 1 DAY
<br />HOURS MNS.
<br />QTBE&D Numb* :NomW LYC
<br />D Daasdantslionle
<br />D OEna(BPsCIy)
<br />Sd. COUNTY OF DEATH
<br />Adams
<br />or. ZIP CODE
<br />68801
<br />tlb. LICENSE NO.
<br />arwtoWN :::..:.
<br />Grand Island
<br />21b.IF TRANSPORTATION
<br />❑ DdwHOp.wtor
<br />D Passenger
<br />❑ Pecan
<br />D Mgr
<br />/397'
<br />Maiden
<br />22c. PLACE OF INJURY -At horns, firm, streak factory, Gila building, °on
<br />W
<br />u
<br />Asa. DATE SIGNED (Mo., Day, Yr.)
<br />•
<br />S1ANfLEY DOPER_
<br />A SFSTAN A7trE REGISTRAR
<br />©El?A'{ZTIt1 OF HEALTH AND
<br />HUMAN gpvicEs •
<br />24c. PRONOUNCED DEAD - (Mo., Day, Yr.)
<br />26 IMD T' 0 USE CONTRIBUTE TO THE DEATH? `.21.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />.., D YES MO 0 PROBABLY I 0 UNKNOWN D YES
<br />340, Hastings, NE 68901
<br />DATE OP DEATH(Mo.
<br />February 22, 2013 `>
<br />d. DATE OF SIRTHIM ..:Day, Yr.)
<br />ecember 16, 1941
<br />2441116E OF DEATH
<br />lg. INSIDE CITY LIMITS
<br />® Yes El No
<br />145.: RELATIONSHIP TO DECEDENT
<br />Sister
<br />DATE(Mo. DIY. Yr.)
<br />February 28, 2013
<br />STATE
<br />Nebraska
<br />1 T4 Vp Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />1 19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />D vas D No
<br />21e. WAS AN AUTOPSY PERFORMED?
<br />OYES 31 NO
<br />led. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />le No
<br />24d. TIME PRONOUNCED DEAD
<br />PATE FILED BY REGISTRAR (PO., Day, Yr.)
<br />MAR 202013
<br />m
<br />214 On Um basis of aamblaton eadlor InvNSgaOOR, In my opinion deat occurred
<br />at the lime, date and place end deo to the case(.) elated. (Egnabus and Tills)
<br />20. WAS CONSENT GRANTED?
<br />Not Applicable Bla Is NO D YES 13 NO
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