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WHEN THIS COPY CARRE:S THE RAISED SEAL OF THE NEBRASKA HEALTH L SYSTEM, IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGIlktAq THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST V T THE LEGAL DEPOSITORY FOR VITAL RECORDS. - DATE OF ISSUANCE 20000036 s SEP 21 1998 HEALTH LINCOLN, NEBRASKA ' STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE VITAL STATISTICS d11UD "V Tdl A TR Air n1P A TLd - 3. DATE OF DEATH /Alonrn. Day. Year) Steven Charles Avila m September 13, 1998 o C-> (n o M UNDER 1 DAY 8. DATE OF BIRTH (MorIIL Day. Year) 5D. MOS. DAYS --4 Grand Island Nebraska cu June 14 1951 NU 7. SOCIAL SECURTIV NUMBER 8a. PLACE OF DEATH ❑ inpatient OTHER: ® Nursing Home c M M M m v F] Homicide Investigatlm aG7 NTY OF DEATH Sc. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDL�L O Grand Island Yes ll y .. -got. STREETANDNUMBE R Ikrc '1g Zip Code) - i�a- INSsLYTV LN+MTS Ei I Nebraska Hall Grand Island 3019 South North Road, 68803 Yea ❑X ND ❑ `�s 27b. DATE SIGN D /MO. Da 27c. TIME OF DEATH 10. RACE - (fig.. White. Blacle American Indian. 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) 1 .. CY 12 � MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /e and. give maiden name) o riISFAic f� NEVER DIVORCED xM D 00 O of WHEN THIS COPY CARRE:S THE RAISED SEAL OF THE NEBRASKA HEALTH L SYSTEM, IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGIlktAq THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST V T THE LEGAL DEPOSITORY FOR VITAL RECORDS. - DATE OF ISSUANCE 20000036 s SEP 21 1998 HEALTH LINCOLN, NEBRASKA ' STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SE VITAL STATISTICS d11UD "V Tdl A TR Air n1P A TLd JERVICES VU WITH ftlillftfif IS I . DECEDENT - NAME FIRST MIDDLE LAST - 3. DATE OF DEATH /Alonrn. Day. Year) Steven Charles Avila m September 13, 1998 o C-> (n o Q UNDER 1 DAY 8. DATE OF BIRTH (MorIIL Day. Year) 5D. MOS. DAYS --4 Grand Island Nebraska cu June 14 1951 NU 7. SOCIAL SECURTIV NUMBER 8a. PLACE OF DEATH ❑ inpatient OTHER: ® Nursing Home 506-58 -TI HOSP_ITAL: M ❑ ER Outpatient ❑ Residence ❑ DOA ❑ Other ($QeL"I m C:) F] Homicide Investigatlm Yes ❑ No ❑ NTY OF DEATH Sc. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDL�L O Grand Island Yes ll y .. -got. STREETANDNUMBE R Ikrc '1g Zip Code) - i�a- INSsLYTV LN+MTS Ei I Nebraska Hall Grand Island 3019 South North Road, 68803 Yea ❑X ND ❑ `�s 27b. DATE SIGN D /MO. Da 27c. TIME OF DEATH 10. RACE - (fig.. White. Blacle American Indian. 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) 1 .. CY 12 � MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /e and. give maiden name) o riISFAic f� NEVER DIVORCED xM D 00 O 14s. USUAL OCCUPATION /Give kindd work done during most 14b. KIND OF BUSINESS INDUSTRY �n 15. EDUCATION ISpecily only highest grade compeedl Secondary 10 -121 CoBega 11 -4 or 5.1 Eemerly 32b. DATE FILED BY REGISTRAR /Ma. Day. Yr.) d working tile, even a reeredl Tool and Die Maker Bullet Manufacturing or 1L cv c;1 • 117 Charles Avila Dolores Re na a =3 18. WAS DECEASED EVER IN U.S. ARMED FORCES? tga. INFORMANT - NAME W Cindy Avila 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY Oct TOWN. STATE. ZIP) 3019 S. North Rd., Grand Island, Nebraska 68803 C 2p. �MB1tL . SIGN R CENSE N N tin e U/ / f �e7 © Bunal ❑ 1..., Cn Grand Island City Cemetery JERVICES VU WITH ftlillftfif IS I . DECEDENT - NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /Alonrn. Day. Year) Steven Charles Avila Male I September 13, 1998 4. CITY AND STATE OF BIRTH lent n USA.. Mme ootaay) Sa. AGE • Last Bi;;;, UNDER 1 YEAR UNDER 1 DAY 8. DATE OF BIRTH (MorIIL Day. Year) 5D. MOS. DAYS Sc. HOURS' MINS. Grand Island Nebraska (Yrs.l 47 June 14 1951 NU 7. SOCIAL SECURTIV NUMBER 8a. PLACE OF DEATH ❑ inpatient OTHER: ® Nursing Home 506-58 -TI HOSP_ITAL: Suicide Pending ❑ ER Outpatient ❑ Residence ❑ DOA ❑ Other ($QeL"I 8b. FACILITY -Name Po nit rraehredn, give afreet an number) St. Francis ; Skilled Care F] Homicide Investigatlm Yes ❑ No ❑ NTY OF DEATH Sc. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDL�L Grand Island Yes ll 27a. DATE OF DEATH /MO.. Day Yr.) .. -got. STREETANDNUMBE R Ikrc '1g Zip Code) - i�a- INSsLYTV LN+MTS Ei I Nebraska Hall Grand Island 3019 South North Road, 68803 Yea ❑X ND ❑ `�s 27b. DATE SIGN D /MO. Da 27c. TIME OF DEATH 10. RACE - (fig.. White. Blacle American Indian. 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) 1 .. CY 12 � MARRIED ❑ WIDOWED 13. NAME OF SPOUSE /e and. give maiden name) co staled. riISFAic American NEVER DIVORCED Cindy Martin 14s. USUAL OCCUPATION /Give kindd work done during most 14b. KIND OF BUSINESS INDUSTRY �n 15. EDUCATION ISpecily only highest grade compeedl Secondary 10 -121 CoBega 11 -4 or 5.1 Eemerly 32b. DATE FILED BY REGISTRAR /Ma. Day. Yr.) d working tile, even a reeredl Tool and Die Maker Bullet Manufacturing or 1L 18. FATHER -NAME FIRST MIDDLE UST . MOTHER FIRST MIDDLE MAIDEN SURNAME • 117 Charles Avila Dolores Re na a 18. WAS DECEASED EVER IN U.S. ARMED FORCES? tga. INFORMANT - NAME (Yes. rq. or unk.l l8 yes. give war and dates of services) No Cindy Avila 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY Oct TOWN. STATE. ZIP) 3019 S. North Rd., Grand Island, Nebraska 68803 2p. �MB1tL . SIGN R CENSE 21 a. METHOD OF DISPOSITION 21b. DATE 21 c. CEMETERY OR CREMATORY -NAME U/ / f �e7 © Bunal ❑ 1..., 09/17/1998 Grand Island City Cemetery a. FUNERAL HUME - AME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Apfel- Butler- Geddes Funeral Home ❑ cramalipt ❑ Donation Grand Island, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) 1123 West Second Grand Island, Nebraska, 68801 -5899 23 1 MEDIATE CAUSE (ENTER ONLY ONE CAUS PER LINE FOR dal. (bl. AND (c I J Interval beh~ or" and death /` - I , , I C C'1 / PART gtt, • (a) ) rtlerval between onset and a DUE TO, OR AS A CONSEO N OF Q� q t , - . _ - r . @I wl7 - I Interval Decwssn onset and deem DUE TO. OR AS A CONSEQUENCE / I K (cl O CONDITIONS - Conditions contributing to the death but riot related PREGNANCY III IF FEMALE. M PAST 3 MONTHS? AUTOPSY SE rfART s No 26b. DATE OF INJURY (Ato.. Day. YcJ 26c. HOUR OF INJURY 280. DESCRIBE MOW INJURY OCCURRED F] Accident Undete -ned M Suicide Pending 26e INJURY AT WORK 261. deice bu,l ding eUtRY /Spew farm, street. factory LLAA E A( 28g. LOCATION STREET OR R.F.D. NO, CITY OR TOWN STATE F] Homicide Investigatlm Yes ❑ No ❑ 27a. DATE OF DEATH /MO.. Day Yr.) 288. DATE SIGNED (Mo.. Day. Yrl 28b. TIME OF DEATH Ei I a .. M DEAD ~1 `�s 27b. DATE SIGN D /MO. Da 27c. TIME OF DEATH 28c. PRONOUNCED DEAD IMO.. Day, Yrl 28d. PRONOUNCED 4Yr/ M M 8 F 27d TO dw st ot my knowledge. m oc rred at tl1s time, date an dace end due to the the b B tiW my op v 28e. On the basis d examination and�w Invsa peon, opinion death occurred at a the time date and place and due a de caLtW$l atNed co staled. (5 nature and Title ► (Signature end Tide 29.,DID T B USE CONTRIBUTE T E DEATH? Xa HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30�p WAS CONSENT❑ES GRANTED? �O � UNKNOWN ❑ aV/` 31. NAME AND ADDRESS OF CE rill (PHYSICIAN, CORONE S PHYSICIAN OR COUNTY ATTORNEY) /Type or phrilllll Dr. Sitki Copur, 2116 West Faidley Ave and Islam N aska 68803 32b. DATE FILED BY REGISTRAR /Ma. Day. Yr.) 32a. REGISTRAR X90610 • 181998 - v