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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Eulalio Ramirez 2. SEX r Ma1ej -, 3 DA}€ F D (Mo., Day, Yr.) �L;V O r0 25, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Horton, Kansas 5a. AGE - Last Birthday (Yrs.) 85 5b. UNDER 1 YEAR 5c. ONDER may, 6. DATE 'bF BIRTH (Mo., Day, Yr.) February 12, 1930 MOS. DAYS HOURS ' ' MINS., 7. SOCIAL SECURITY NUMBER 507 -24 -5525 8b. FACILITY -NAME (If not Institution, give street and number) 409 W. 12th Street 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ ER/Outpatient ® Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68801 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 409 W. 12th Street 9e. APT. NO. I 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ID Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Angelita Picon 11. FATHER'S -NAME (First, Middle, Last, Suffix) Seferino Ramirez 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Carmen Contreras 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 12/27/1948- 12/26/1951 14a. INFORMANT -NAME George Ramirez 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER- SIGNATURE Katie M. Smydra 16b. LICENSE NO. 1454 16c. DATE (Mo., Day, Yr.) March 31, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 [] To be completed by: CERTIFIER 1 1 CAUSE OF DEATH (See instructions and examples) 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, APPROXIMATE INTERVAL onset to death 14 Days respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: i onset to death Sequentially list conditions, if b) Pulmonary Fibrosis i 3 Years any, leading to the cause listed I 1 on line a. DUE TO, OR AS A CONSEQUENCE OF: I onset to death Enter the UNDERLYING CAUSE c) Chronic Obstructive Pulmonary Disease 1 5 Years (disease or injury that Initiated the events ents resulting in death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death d) 1 1 . 18. PART 11. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting In the underlying cause given in PART 1. Cor Pulmonale Heart Failure 19. WAS MEDICAL. EXAMINER OR CORONER CONTACTED? ❑ YES Ea NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death U unknown if pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES 13 NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8. NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE SW i3 F E El a 23a. DATE OF DEATH (Mo., Day, Yr.) March26,2015 Z ; 0 v Y N.4 c u W z 8 z ~ g a 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) March 30, 2015 23c. TIME OF DEATH I 08:02 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 < 0 3d. To the best of my knowledge, death occurred at the time, date and place 2 o and due to the cause(s) stated. (Signature and Title) o Isaac J. Berg, MD 24e. On the basis of examination and /or investig tion, in my opinion death occurred at the time, date and place and due to the cau els) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 265. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Isaac J. Berg, MD, 729 North Custer Avenue, PO Box 2339, Grand Island, Nebraska, 68803 • 1 28a. REGISTRAR'S SIGNATURE 4 au_- pv 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 1, 2015 DATE OF ISSUANCE 04/06/2015 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. STANLEY-5, gre ASSISaAIV ST 201503378 DEpARTMENT-Ogh LINCOLN, NEBRASKA HUMANI STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICE CERTIFICATE OF DEATH 15 01923