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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL7rbYANh t- ib1i41(AI SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA aPARrMEN7t QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR .VITAL. RECORD. `i A
<br />i s
<br />DATE OF ISSUANCE
<br />01/16/2014
<br />LINCOLN, NEBRASKA
<br />201400975 'E o P
<br />}' E ASSISTIf % 9 EGI ‘, +DARTMEN H
<br />' HEIN a V $ERVZCES , :.; '
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S f' F t ,A : ' ' , ,,,,*
<br />CERTIFICATE OF DEATH 1 , ` "" ,,;'
<br />13 05786
<br />1. DECEDENTS-NAME (First, Middle, Last, Suffix)
<br />Diana Sue Rivas
<br />2. SEX ` I ,;
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />December 28, 2013
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />60
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />' 6. DATE OF BIRTH (Mo., Day, Yr.)
<br />July 27, 1953
<br />MOS.
<br />I
<br />DAYS
<br />HOURS
<br />MINE.
<br />7. SOCIAL SECURITY NUMBER
<br />507 -70 -0802
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Saint Francis Medical Center
<br />8a. PLACE OF DEATH
<br />IJOSPITAI, ❑ Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br />® ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />3d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />8b. COUNTY
<br />I Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />3112 W. Schimmer Dr.
<br />e. APT. NO.
<br />r
<br />9f. ZIP CODE
<br />I 68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Henry Gamez Rivas
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Ted Roberts
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ruth Nelson
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Henry Gamez Rivas
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />O Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER-SIGNATURE
<br />Katie M. Ewald
<br />16b. LICENSE NO.
<br />1454
<br />16c. DATE (Mo., Day, Yr.)
<br />January 3, 2014
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events - diseases, Injuries, or compacations.hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Immediate
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Subdural Hematoma - Unknown If Traumatic Or Spontaneous
<br />disease or condition resulting
<br />In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially list conditions, N b)
<br />any, leading to the cause listed
<br />anti
<br />on a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that Initiated
<br />Uw events resetting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />LAST d)
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS•Condltions contributing to the death but not resulting In the underlying cause given in PART I.
<br />atrial fibrillation, renal insufficiency, diabetes type 2,Chronic Obstructive Pulmonary Disease
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />,20. IF FEMALE:
<br />® Not pregnant within peat year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21 b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES El NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />b
<br />LL
<br />J
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />i
<br />- 2 ,
<br />g °
<br />§ .t
<br />w
<br />2 ? 3
<br />o
<br />- 24a. DATE SIGNED (Mo„ Day, Yr.)
<br />J 15, 2014
<br />24b. TIME OF DEATH
<br />06:19 AM
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />December 28, 2013
<br />24d. TIME PRONOUNCED DEAD
<br />06:19 AM
<br />ore
<br />8 3d. To the best of my knowledge, death occurred at the time, date and place
<br />A a and due to the cause(s) stated. (Signature and Title)
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />the time, date and place and due to the causes) stated. (Signature and Tale)
<br />Barbara Dunn, Hall Deputy County Attomey
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES 0 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Barbara Dunn, Hall Deputy County Attomey, 231
<br />S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />128a. REGISTRAR'S SIGNATURE /1 . A - n . -
<br />/ / �a/�`■ ~ r • � 'v
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />January 15, 2014
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL7rbYANh t- ib1i41(AI SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA aPARrMEN7t QF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR .VITAL. RECORD. `i A
<br />i s
<br />DATE OF ISSUANCE
<br />01/16/2014
<br />LINCOLN, NEBRASKA
<br />201400975 'E o P
<br />}' E ASSISTIf % 9 EGI ‘, +DARTMEN H
<br />' HEIN a V $ERVZCES , :.; '
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN S f' F t ,A : ' ' , ,,,,*
<br />CERTIFICATE OF DEATH 1 , ` "" ,,;'
<br />13 05786
<br />
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