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To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Alexander Esparza 2. SEX ' 'i' Male 3rb rlE.bFV,FAf (Mo., Day, Yr.) ; January 48,2016 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Wellington, Kansas 5a. AGE - Last Birthday 613. UNDER 1 YEAR 5c. UNDER 1 DAY 6, DATE DP-BIRTH (Mo., Day, Yr.) October 2, 1931 (Yrs.) 84 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 511 -24 -4411 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 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 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 419 West 17th Street 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Margaret Ann Walker 11. FATHER'S -NAME (First, Middle, Last, Suffix) Refugio Jose Esparza 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Cerarea Canales 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Margaret Ann Esparza 14b. RELATIONSHIP TO DECEDENT Wife 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.) January 26, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) To be completed by: CERTIFIER 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 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: onset to death IMMEDIATE CAUSE (Final a) recurrent Aspiration Pneumonia Months disease or condition resulting in death) DUE TO, OR AS A CONSEQUENCE OF: : onset to death Sequentially list conditions, if b) Parkinsons Disease 1 Years any, leading to the cause listed � on line a. DUE TO, OR AS A CONSEQUENCE OF: 1 1 onset to death Enter the UNDERLYING CAUSE c) I (disease or injury that Initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: ■ onset to death LAST 1 d) 1 1 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Malnutrition 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®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 ❑ 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 21d. 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 ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE S W 1 F E tJ 23a. DATE OF DEATH (Mo., Day, Yr.) January 18, 2016 z a 5 z re $ 1+ c a. 4 c u 1, g 2 0 o ~ 0 a 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) January 18, 2016 23c. TIME OF DEATH 02:28 AM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 7d. To the best c knowledge, death occurred at the time, date and place 2 and due to the cause(s) stated. (Signature and Title) S Sara Graybill, MD urred at 24e. On the the time, basis date of examination and place and and /or due to investigationthe causes) , stated. (Si in my opinion gnature death and occ Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR ❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ISSUE r • ATION BEEN CONSIDERED? IZ NO 26b. WAS CONSENT GRANTED? Not Applicable if 26s is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sara Graybill, MD, 2116 W Faidley #400, Box 9802, Grand Island , Nebraska, 68803 I �f 128a. REGISTRAR'S SIGNATURE ii 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) January 25, 2016 STATE OF NEBRASKA 1091.1+41 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 DEPA T ENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITALR CO1 g: \ t DATE OF ISSUANCE 01/29/2016 LINCOLN, NEBRASKA STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICkS- CERTIFICATE OF DEATH ST (NL4rS. OPER AtS STANT STArE.IREGISThAP // DEPARTME H ALTH AND r HUI IN S L, 16 00310