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To be completed /verified by: FUNERAL DIRECTOR
<br />1
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Vincent Alexander Moreno Sr
<br />2. SEX ":
<br />Male
<br />3. DATE "OF DEATH (Mo., Day, Yr.)
<br />March 17, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Alda, Nebraska
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />77
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />April 21, 1937
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />505 -38 -6424
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />522 W. 2nd Street
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ 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 68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />522 W. 2nd Street
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />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 />Rebecca Cornelio
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Marcos Moreno
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Louise Ramirez
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 01/02/1957- 06/01/1962
<br />14a. INFORMANT -NAME
<br />Marcus Pete Moreno
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER - SIGNATURE
<br />Katie M. Smydra
<br />16b. LICENSE NO.
<br />1454
<br />16c. DATE (Mo., Day, Yr.)
<br />March 23, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Grand Island City Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING 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 />To be completed by: CERTIFIER
<br />18. PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Undetermined Natural Causes
<br />disease or condition resulting
<br />in death( DUE TO, OR AS A CONSEQUENCE OF: : onset to death
<br />Sequentially list conditions, if b) 1
<br />any, leading to the cause listed I
<br />I
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />Enter the UNDERLYING CAUSE c) I
<br />(disease or injury that initiated .
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death
<br />LAST d) 1
<br />I
<br />1
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past 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 />ID Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® 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 />DYES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />a W
<br />z F
<br />W
<br />E O Z
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />; E Il
<br />$
<br /><J
<br />1ta0
<br />2
<br />o p
<br />0 o
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />March 20, 2015
<br />24b. TIME OF DEATH
<br />Approx. 06:00 PM
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />March 17,2015
<br />24d. TIME PRONOUNCED DEAD
<br />08:17 PM
<br />a O 23d, To the best of my knowledge, death occurred at the time, date and place
<br />It G and due to the cause(s) state (Signature and Title)
<br />24e. On the basis of examination andlor investigation, in my opinion death occurred at
<br />the time date and place and due to the cause(s) stated. (Signature and Title)
<br />Jack Zitterkopf, Hall County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR
<br />❑ YES
<br />ISSUE a • ATION BEEN CONSIDERED?
<br />IZI 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 />Jack Zitterkopf, Hall County Attorney, 231 S. Locust,
<br />P.O. Box 367, Grand Island, Nebraska, 68802
<br />1 28a. REGISTRAR'S SIGNATURE A - _ - Y � V
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />March 24, 2015
<br />DATE OF ISSUANCE
<br />05/13/2015
<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPAIMTMENT OF HEA4TH',$"1b N SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEB I$KAPDtPARTM T OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOIE -V.IAL RECORDS/
<br />201503071 STANL g $.,COOPER V
<br />ASSIStAN'pS ' T REGISTRAR
<br />DEPARTMENT EALTHANC
<br />LINCOLN, NEBRASKA HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICE - ?
<br />CERTIFICATE OF DEATH
<br />15 01755
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