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Rev. 11 /97 <br />0) <br />O <br />0 <br />U <br />a <br />c <br />0 <br />U <br />O <br />U) <br />E <br />ro <br />x <br />v <br />11 <br />U <br />Z E <br />W <br />C <br />W . <br />5 <br />W <br />0 t <br />LL. <br />Os <br />W °) <br />Q <br />Z 11 <br />C7 <br />M <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />14 <br />FOR VITAL STATISTICS USE ONLY <br />Place A B C D E Part II TMV <br />NSC Census Tract No. <br />Work <br />UC <br />Reject <br />Printed with Ink on recycled paper <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />Juanita (NMI) Roman <br />2. SEX <br />Female <br />3. DATE OF DEATH /Month, Day. Year) <br />December 30, 2001 <br />4. CITY AND STATE OF BIRTH Ill not in U.S.A.. name country( <br />C o t u l l a, Texas <br />5a. AGE - Last Birthday <br />(urea <br />86 6 <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Monet. Day. Year( <br />April 25, 1915 <br />5b. MOS. i DAYS <br />Sc. HOURS MINS. <br />Z <br />O 505-76-9985 <br />w <br />V <br />w <br />C <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE <br />OF DEATH <br />HOSPITAL: Inpatient OTHER: © Nursing Home <br />ER Outpatient Residence <br />[] DOA Other (spec,,y, <br />8b. FACILITY - Name (! /rot rhstifuG'on, give street and number) <br />Beverly Health Care - Lakeview <br />1 <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />Grand Island, <br />8d. INSIDE CITY LIMITS <br />Yes X No <br />88. COUNTY OF DEATH <br />Hall <br />9a. RESIDENCE - STATE <br />Nebraska <br />9b. COUNTY <br />Hall <br />9c. CITY. TOWN OR LOCATION <br />Grand Island <br />9d. STREET AND NUMBER (Including Zip Code) <br />808 E. 5th St. 68801 <br />9e. INSIDE CITY LIMITS <br />Yes X No <br />10. RACE - (e.g., While. Black. American Indian. <br />etc.) ISoeciy) Hispanic <br />11. ANCESTRY (e.g.. Italian. Mexican, Getman, etc) 12. ❑ MARRIED fi: �+7 WIDOWED <br />)Specify) Mexican • NEVER DIVORCED <br />MARRIED 1 <br />13. NAME OF SPOUSE (I/ wee. give maiden name) <br />14a. USUAL OCCUPATION (Glee kind of work done during most <br />of working lime, even i7retired/ <br />Home maker <br />14b. KIND OF BUSINESS INDUSTRY <br />Domestic <br />15. EDUCATION (Specify only highest grade completed) <br />Elementary or Secondary (0 -12) College It - or 5•1 <br />0 <br />16. FATHER - NAME FIRST MIDDLE LAST ' <br />Paiblo Salaz <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Simona (Unknown) <br />3sne3 <br />18. WAS DECEASED <br />(Yes, no, or unk.) <br />No <br />EVER IN U.S. ARMED FORCES? <br />1 (If yes. give war and dates of services) <br />19a. INFORMANT - NAME <br />Tony Roman <br />19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) <br />3007 W. 15th St., Grand Island, NE 68803 <br />20. ALMER - SIG T R <br />CENS a 218. <br />C <br />#1071 <br />METHOD OF DISPOSITION <br />© Burial Removal <br />21b. DATE <br />January' 3, 2002 <br />21c. CEMETERY OR CREMATORY NAME <br />Wect1arin M13 a ial Park CHnetezy <br />22S FUNERAL H ME - NAME (J <br />All Faiths Funeral Home <br />Cremation Ll Donation <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />2929 S. Locust St., Grand Island, Nebraska 68801 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). lb). AND (c)) Interval between onset and deem <br />PART - ; <br />DUE TO, OR AS A CONSEOUENCE OF Interval between onset and death <br />Ibl <br />¢ <br />_ W <br />W <br />F- <br />CC <br />LU 0. <br />DUE TO, OR AS A CONSEOUENCE OF: <br />(c) <br />Interval between onset and death <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related <br />PART <br />11 <br />PART III IF FEMALE. WAS THERE A <br />PREGNANCY IN THE PAST 3 MONTHS? <br />(Ages 10 -54) Yes I n I No <br />24 AUTOPSY <br />Yes n No Y1 <br />25. WAS CASE REFERRED TO MEDICAL <br />EXAMINER OR CORONER? <br />Yes n No ) <br />' <br />26a. <br />. Accident 0 .Undetermined <br />• Suicide i Pending <br />Homicide Investigation <br />• r <br />26b. DATE OF INJURY (Mo.. Day. Yr.) <br />OF INJURY <br />M <br />26d. DESCRIBE HOW INJURY 0 U U 8D ! ( <br />26e. INJURY AT WORK <br />Yes N o <br />261. PLACE At hog. larm. street factory <br />d ipe b spac <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />a= <br />I a <br />2 <br />.e .f <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />December 30, 2.001 <br />28a. DATE SIGNED (MO.. Day. Yr I <br />28b. TIME OF DEATH <br />M <br />271. DATE SIGNED (Mo.. Day. Yr) <br />January 4 +t01 <br />27c. TIME OF DEATH <br />7:50 am <br />le Completed <br />VERS PLAYS! <br />JNTY ATTOP <br />ONLY <br />28c. PRONOUNCED DEAD (Mo.. Day, Yr./ <br />26d. PRONOUNCED DEAD (Hour( <br />M <br />27d. To the best of my know = • • th occ rod at the ' e, a and place and due to the <br />causels) slated. <br />(Signature and Title) <br />28e. On the basis 01 examination and•or investigation, in my opinion death occurred at <br />Me time, dale and place and due to the causes) stated. <br />'(Signature and Title) ► <br />29. 0(0 TOBACCO USE CONT UT • ' E DEATH? <br />YES • UNKNOWN <br />.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />fl YES A. NO <br />30.b WAS CONSENT GRANTED? ��' (((� <br />YES }may NO <br />l� <br />31. NAME AND ADDRESS cE'n I ER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type a - ' -) <br />John A. Wagoner M.D., 800 Alpha St., Grand Island, Nebraska 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) <br />Rev. 11 /97 <br />0) <br />O <br />0 <br />U <br />a <br />c <br />0 <br />U <br />O <br />U) <br />E <br />ro <br />x <br />v <br />11 <br />U <br />Z E <br />W <br />C <br />W . <br />5 <br />W <br />0 t <br />LL. <br />Os <br />W °) <br />Q <br />Z 11 <br />C7 <br />M <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />14 <br />FOR VITAL STATISTICS USE ONLY <br />Place A B C D E Part II TMV <br />NSC Census Tract No. <br />Work <br />UC <br />Reject <br />Printed with Ink on recycled paper <br />