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<br />1. DECEDENTS-NAME (First, Middle, Last, Suffix)
<br />Donnie Chavez
<br />2. SEX
<br />Male
<br />3. DATE OF (Mo.,Dey,Xr.)
<br />February 14, 2015
<br />4. CRY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />Sa. AGE -Last Birthday
<br />(WO
<br />57
<br />fib. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />9. DATE OF BIRTH (Mo., Day, Yr.)
<br />November 1, 1957
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINE.
<br />• 7. SOCIAL SECURITY NUMBER
<br />505- 78 -8861
<br />8a. PLACE OF DEATH
<br />HOSPITAL: ® Inpatient QT in; ❑ Nursing Hom<C ❑ Hospice Facility
<br />❑ ERIOUtpatient ❑ Decedent's Home
<br />0 DOA ❑otit.r(Speoly)
<br />8b. FACILITY-NAME (If not institution, give street mdnumbw)
<br />CHI Health St. Francis
<br />Bc. CITY OR TOWN OF DEATH (Include Zip Cede)
<br />Grand Island 68803
<br />Ed. 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 AID NUMBER
<br />;.2109 Viking Rd
<br />9s. APT. NO.
<br />Si. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />®vee ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH EaMerrled ❑ Never Men
<br />❑ Monied, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nano.
<br />Nancy Kay Hendrix
<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />Thomas Chavez
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Mary Reynaga
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yea, No, or Unit.) Ng
<br />14s. INFORMANT-NAME
<br />Nancy Kay Chavez
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />®9anr ❑ onaa.n
<br />❑CnmWon ❑EntomMnMa
<br />❑Remavel ❑OTheNSpeelN)
<br />1 NA
<br />+���� , m 4ATTt
<br />18b. LICENSE NO.
<br />146
<br />18e. DATE (Me., Day. Yr.)
<br />February 21, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITYfTOWN STATE
<br />Westlawn Cemetery Grand Island Nebraska
<br />175. FUNERAL HOME NAME AND MAILING ADDRESS (Sheet. 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 />1e. PART t. Enter the obded. tr..we a eAb,p,I.a, edeathDONOTentere mdnd events each se weal meet, APPROXIMATE INTERVAL
<br />n.ptmtory avert. or w,t4mIar fibrillation without eltaevheptM etiology. 00NDT A9 INIPAATE Deter only one ewes on • line. Add addtitonel ante Eeam spy.
<br />IMMEDIATE CAUSE: onset to death
<br />IMMEDIATE CAUSE (Final �t /‘/fours
<br />cheese a conxlNlen resulting a) jevere . r / u r i
<br />M death)
<br />DUE TO, OR AS A CONSEQUENCE OR onset to death
<br />Sequentially list conditions, N (� L t' �j e /(t / hour
<br />any, leading to the cause listed °) .,J a blur rag c n n0 G/ / + em
<br />on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Enter the UNDERLYING CAUSE c)
<br />(disease MANY lg DUE TO, OR AS A CONSEQUENCE OF: onset to deal°
<br />events moulting In death) WOO"
<br />LAST
<br />d)
<br />18. PART S. OTHER SIGNIFICANT COIDFT1ON&Conditiaxe 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 />C1 YES ej NO
<br />I 20. IF FEMALE:
<br />❑Net pregnant within past year
<br />j ❑Pregnant at time of death
<br />❑Hot pregnant, but pregnant within 42 days of death
<br />1 [Not pregnant, but pregnant 43 days to 1 year before death
<br />S ❑Unknown E pregnant within the past year
<br />g
<br />21a. MANNER OF DEATH
<br />- Nannal ❑ Homicide
<br />firj AcoldeM ❑ Pending investigation
<br />❑ Suicide 0 Could not be detr alned
<br />21b. IF TRANSPORTATION INJU
<br />❑ Drlv erfOPeoator
<br />❑ Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />OYES NO
<br />a
<br />21d. MERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES Q' NO
<br />1
<br />225. DATE OF INJURY (Mo., Day. Yr.)
<br />$ Fe 6 ruary /3 a /S
<br />226. TIME OF INJURY
<br />/50o m
<br />22d. PLACE OF INJURY-At home, farm, sheet, factory, office building, construction site, etc. (Specify)
<br />Af home
<br />S Rd. INJURY AT WORK?
<br />❑ YES am
<br />22e. DESCRIBE HOW INJURY OCCURRED L .�, { /!
<br />p)fienf was /valid down by his w /�e in hrs a bath /wet . / e A)4S atviespcoVix
<br />22f. LOCATION OF INJURY • STREET. S. MJMBER,APT. M O. CITYITOWN STATE ZIP CODE
<br />2/ V: kin y Road , C Island N 6SS0 3
<br />kw
<br />1 ,v
<br />.1g
<br />2 a
<br />23a. DATE OF DEATH (Mo. Day, Yr.)
<br />rebmierr 14-A. a "S
<br />Z
<br />E s
<br />Y O
<br />o
<br />240. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />23b. DATE SIGNED (Mb.. Day, Yr.)
<br />Thiwary.2 art/ , 10/5'
<br />23d. To the best of my;knowlsdge, death occurred
<br />and due to s) stated. (Signature
<br />23x. TIME OF DEATH
<br />o9/3 a•.. m
<br />at the time, date and place
<br />and Title)
<br />24e. On e heels of examination and/or Investigation, M death my opinion dea occurred
<br />th
<br />at the time, date and place and due to the cause(e) stated. (Signature and Title)
<br />25. DID TOBAC USE CONTRIBUTE TO 1HE DFATH?
<br />El YES Ui+ NO ❑ PROBABLY ❑ UNKNOWN
<br />26a. ,H,A{S ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />yJ YES ❑ NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable It 26a is NO , 'YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />) „,...,
<br />Scar n 1k 42.4,, / it) log Ai. /4,0 s 'live . Suit bye C rood 15.440/. NE 6gg o 3
<br />•--.-/ 28a. REGISTRAR'S SIGNATURE
<br />P J (
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) I
<br />FEB 25 2015
<br />STATE OF NEBRASKA
<br />201504925
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEP4RTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL ReCDR ,
<br />DATE OF ISSUANCE
<br />02/27/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVIC
<br />STAN eY . COOPER' '\. • .
<br />ASSISTANT STATE REGISTRAR',
<br />9EPART NT.QP 41.TH A) F
<br />HOMANh t5'
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