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22d, INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE � LL I- 6 O W .. 23a. DATE OF DEATH (Mo., Day, MA..")) Gin. 1� Yr.) a O i 1 Z XI Ll Z ge e 2 0 Ep O. o tJ W li S 23d. 2 O O O C g F- O U o TISSt DONATION L!J NO 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH m 23b. DATE SIGNED (Mo., Day, M arc '4 . ( Yr.) Z- I 23c. TIME OFDEATH 4 Z p m 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD m To the best of my knowledge, death occurred at the time, date and place d theca ) stated. (Sig re and Title) 24e. On the basis of examination andlor investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACC USE CONTRIBUTE TO THE DEATH? ❑ YES E1 NO ❑ PROBABLY ❑ UNKNOWN 28a. HAS ORGAN OR ❑ YES BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Luris Decalero M.D. 2116 W. Faidley Av #400 Grand Island, NE 68803 28a. REGISTRAR'S SIGNATURE AC. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) MAR 18 2011 0 V m 0 I- STATE OF NEBRASKA 01602577 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AMY latiA7V1/290VICES, IT CERTIFIES THE BELOW TO OE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA' D PA THE ,Pr O 'HEALTH AND V HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 1- 44•14EGOBF,a • v DATE OF ISSUANCE MAR 302011 Amended March 30. 2011 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Benjamin Melendez -Rivas 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Mexico 9d. STREET AND NUMBER 1520 St. Paul Rd 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S-NAME (First, Middle, Last, Suffix) Calletano Melendez 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Link.) No 15. METHOD OF DISPOSITION Bwiai Donation ❑Crem.don ❑EMomb eM ❑Removal ❑Other(8pecify) HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska Enter the UNDERLYING CAUSE e) (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST 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 16a. EMBALMER - SIGNATURE., / , 16d. CEMETERY, CREMATO RY OR OTHER LOCATION 5a. AGE -Last Birthday (Yrs.) 63 14a. INFORMANT -NAME Maria E Melendez MOS. 2 a MANNER OF DEATH Natural ❑ Homicide Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 6b. UNDER 1 YEAR DAYS 2. SEX Male Sc. UNDER 1 DAY HOURS 9e. APT. NO. 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) I wife, give maiden name.. O Maria E 7. SOCIAL SECURITY NUMBER - -567 -63 -6463- 551 9 0 Nb. FAtILI Y -NAME (If not Institution, give street and number) Wedgewood Care Center Bc. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9e. CITY OR TOWN Grand Island OTHER; ® Nursing Home/LTC ❑ Hospice Faeglty ❑ Decedent's Home ❑ Other(SpecKy) 8d. COUNTY OF DEATH Hall 12. MOTHER'S -NAME (First, Middle, Mauricia Rivas MINS. 9f. ZIP CODE 68801 Maiden Surname) 16b. LICENSE NO. 1092 CAUSE OF DEATH (See instructions and examples) 18. PART N. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I. 21b. IF TRANSPORTATION ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) INJURY March 10, 2011 6. DATE OF BIRTH (Mo., Day, Yr.) March 31, 1947 9g. INSIDE CITY LIMITS Yea 0 No 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) 3 -14 -2011 Grand Island City Cemetery CITY/TOWN Grand Island STATE Nebraska 17b. Zip Code 68801 the o everrte - diseases, injuries, orcompIWtlons -that directly caused the death. DO NOT enter terminal events such as mottles arrest, arrest, or ventricularlbraladon without aaow199 the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addltlonal lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final disease or condition resulting In death) a) /''` C'�`GLS'GV��iC.i�� APPROXIMATE INTERVAL onset to death Ma ✓ ; - Sequentially list conditions, If b) any, leading to the cause listed on line a. DUE TO, OR AS A CONSEQUENCE OF: onset to death DUE TO, OR AS A CONSEQUENCE OF: onset to death d) onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES y NO 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.) LINCOLN, NEBRASKA Sr P i' S - COOPER y ASSISTANT '1!' REGI'STRAA- DEPAk.7MENT QF -IEALTH AND. HU141' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH k' 3. DA'rEOF DEATH (Mo,Day,Yr:) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)