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<br />STATE OF NEBRASKA
<br />As% .4 44. ...A
<br />WHEN THIS >: "' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />5/25/2016
<br />LINCOLN NEBRASKA
<br />cior
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />IF..
<br />a
<br />C
<br />0
<br />0
<br />0
<br />1. DECEDENTS- NAME (First, Middle, Last, Suffix)
<br />Joseph Anthony Soto Sr
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand la d, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506 -84 -7110
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a, RESIDENCE-STATE
<br />Nebraska
<br />Sd. STREET AND NUMBER
<br />103 Myrtle Street
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, bct separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Robert Soto
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No or Ufk.) No
<br />15. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />❑ Cremation ❑ Entombment
<br />❑ Remoyal ❑ Other (Specify)
<br />Enter the UNDERLYING CAUSE
<br />::;( diseaae or injury;that initiated.;
<br />the events s- suitin9 death)
<br />LAST;
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20. IF:FEMALE.
<br />❑ Not pregnant:within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant „but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0. Unknown it p egnantwit/ti r the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />April 17, 2016
<br />22b. TIME OF INJURY
<br />10:13 PM
<br />22d, INJURY AT WORK?
<br />❑YES
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />25. DD TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES NO ❑ PROBABLY ❑ UNKNOWN
<br />9b. COUNTY
<br />Hall
<br />23c. TIME OF DEATH
<br />5a. AGE Last Birthday
<br />(Yrs.)
<br />51
<br />14a. INFORMANT -NAME
<br />Leslie Diane Soto
<br />16a. EMBALMER- SIGNATURE
<br />Katie M. Smydra
<br />21a. MANNER OP DEATH
<br />❑ Natural ❑ Homiide
<br />El Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES Ea NO
<br />5b. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 17, 2016
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />28,
<br />64
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />Ea ER/Outpatient
<br />❑ DOA
<br />OTHER ❑ Nursing Home /LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />❑ Hospice Facility
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9c. CITY OR TOWN.
<br />Aida
<br />9e. APT. NO.
<br />16b. LICENSE NO.
<br />1454
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street. Grand Island, Nebraska
<br />21b. IF TRANSPORTATION INJURY
<br />Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />May 20, 2016
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />April 17, 2016
<br />9f. ZIP CODE
<br />68810
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sarah Carstensen, Chief Deputy Hall County Attorney, 231 S. Lo P.O. Box 367, Grand Island, Nebraska, 68802
<br />28a, REGISTRAH'S SIGNATURE��!r
<br />9g. INSIDE CITY LIMITS;.:
<br />El YES ❑ NO
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Leslie Diane Webster
<br />12. MOTHERS-NAME (First, Middle, Maiden Surname)
<br />Linda Davis
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />April 23, 2018
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />St. Mary's Cemetery
<br />CITY / TOWN
<br />Wood River
<br />STATE
<br />Nebraska
<br />17b. Zip. Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1a. PART 1. Enter Me chain of events. - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, orVentricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Injuries To The Head, Trunk, And Extremities As A Result Of A Car Crash
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting
<br />APPROXIMATE INTE
<br />onset to death
<br />Immediate
<br />in death)
<br />list bandit
<br />any, leading to the Isou
<br />on line a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />YES ❑ NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ❑ NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />Roadway Near Hwy 30 And Monitor Rd
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />3 vehicle car crash where the decedent crossed the road and crashed into oncoming traffic. Decedent was ejected
<br />from the vehinte
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN
<br />Roadway near the intersection of Highway 30 And Monitor Rd, Grand Island
<br />STATE
<br />Nebraska
<br />ZIP CODE
<br />68801
<br />24b. TIME OF DEATH
<br />10:51 PM
<br />24d. TIME PRONOUNCED DEAD
<br />10:51 PM
<br />24e. On the basis of examination and /or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />Sarah Carstensen, Chief Deputy Hall County Attorney
<br />26b. WAS CONSENT GRANTED? !"
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Ma,,_Day, Yr..)
<br />May 20, 2016
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