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STATE OF NEBRASKA
<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 SE VICES, VITAL
<br />1
<br />V
<br />DATE OF ISSUANCE STANLL S. COOPER
<br />ASSISTANT STATE REGISTRAR DEPARTMENT MAY 0 9 2017 201703182 HUMAN SERVICES HEALTH AND
<br />LINCOL *- NEBRASKA __ .
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
<br />deaeese or rxrrdition ref uMng
<br />trdeeM)
<br />Seeatdtially Brtcon41lp L 6
<br />DUE TO. OR AS A CONSEQUENCE 0F:
<br />m High blood pressure
<br />1 ousel to death
<br />;unknown
<br />1. DECEDENT'S -NAME rirsl,
<br />Ca r l otta
<br />Middle.
<br />Last
<br />Aguilar
<br />Suffix)
<br />4 CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />Coladas, Jalisco, Mexico,
<br />7 SOCIAL SECURITYNUMBER
<br />507 -24 -1775
<br />Bb. FACILITY -NAME Ht not Institution. glve street and number)
<br />13 916 E. 5th Street
<br />Be. CITY OR TOWN OF DEAT (lfl I de Tip Code)
<br />Grand Island, 68801
<br />3 9a.RESIDENCE -STATE
<br />a NE
<br />u
<br />tSSTREET AND NUMBER
<br />916E. 5th Street
<br />10a. MARITAL STATUS AT TIME OF DEATH d Married ❑ Never Married
<br />m i
<br />m ❑Married, but separated °Widowed Q Divorced ❑ Unknown
<br />11. PAT THER 9-NAME :; {First,
<br />Jesus
<br />Mlddls.
<br />Last,
<br />Salinas
<br />Soots)
<br />13 EVER IN U.S. ARMED FORCES? Give dales of service II yes.
<br />{Yes• no or unk) N o
<br />S. METHOD Of IMPOSITION
<br />v
<br />lareurfa1 QDona(ion
<br />00rema9orl '0 Entombment
<br />°Removal ❑ Other (Specify)
<br />,. �{t.fF'firMAL£
<br />¢ XX Not:tVe9n8Rfwiih?n peal year
<br />V 0 Pregnant at lime of death
<br />a $. ❑ Not pregnant, but pregnanl willful 42 days et death
<br />' ❑ Ndtpragn4a154E pMg0an143 days 10 l year before death
<br />E,] Unknown ll pregnant within the past year
<br />-: 220 PATE OPtNJifRY (MO., Day. Yr.)
<br />ru
<br />02
<br />22d.INJURY AT WORK?
<br />ES?, fl U#
<br />221 - LOCATI
<br />90.000WIY
<br />Hall
<br />160. ES4 E •SIGNATU
<br />22b. TIME OF INJURY
<br />m
<br />5a AGE-Last Birthday
<br />(Yrs.)
<br />86
<br />16d. CEMETERY, CREMATORY 011 OTHERLCIZ
<br />21a. MANNER OF DEATH
<br />a Natural ° Hoade0de
<br />❑ Accident° Pending Investigation
<br />❑ Srncid° ❑ Could nor be determined
<br />k frteft A (m-m
<br />5b. UNDER 1 YEAR
<br />MOs.
<br />4
<br />DAYS
<br />7
<br />'1bl N EC40
<br />2. SEX
<br />Female
<br />Sc. UNDER I DAY
<br />HOURS
<br />la. PLACE OF DEATH
<br />HOSPITAL
<br />❑Inpatient" OM: ❑ Nursing Hooe(LTC ❑Hospice Pachily
<br />❑ ER/OW yy
<br />palienl t7 Decedent's Home
<br />cot Omer(Specifyl ..
<br />9c. CITY OR TOWN
<br />Grand Island
<br />90. APT, NO
<br />I Ob. NAME OF SPOUSE (First, Middle. Last, Suffix) If wile. give maiden name.
<br />Stanley Aguilar
<br />(2. M
<br />THER'S•NA
<br />me (Ftr t,
<br />Maria
<br />Middle,
<br />aarcia
<br />14a. INFORMANTNAME
<br />Stanley Aguilar
<br />Id. COUNTY OF DEATH
<br />Hall
<br />CITY /TOWN
<br />Westlawn Memorial Cemetery Grand Island
<br />PART ti e ni
<br />IGNIFICANT CONDITIONS- Cond,llons conlributIng to the death but not reselling es
<br />e Underlying cause given in PART 1.
<br />IF TRANSPORTATION INJURY
<br />Orrv9riOperator
<br />I° Passenger
<br />O Pedesglan
<br />- ,Q O ner{Specily)
<br />MINS.
<br />8 6 71 8 8 0 F 1
<br />33 �� 0 O 6 EA � -3 -€
<br />MDA TRF FfH 11�>�Oy. 1r )
<br />6. DATE OF BIRTH (Mo., Day. Yr.)
<br />November 4, 1919
<br />14 b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />ter., nATE 'Mo.. Day, Yr. )
<br />March 14, 2006
<br />Nebraska
<br />TM. FUNERAL HOME NAME AND MAIL NG ADDRESS (Sheet. City or Town, Stale) '
<br />lrivingston Sondermann F.H. 601 N. Webb Road Grand Island, NE
<br />9g. 19510E CITY LIMITS
<br />v7
<br />YES ❑ NO
<br />STATE
<br />CAUSE OF DEATH (See Instructions and examples)
<br />18. PART L Enter me chain of events -- diseases. injuries, or complications- -that directly caused the 09019.00 NOT 99101 terminal events swan as cardiac weal,
<br />p1310ry arre$t bbrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one (Ina. Add adddional lines if necessary.
<br />)(IMMEDIATE CAUSE:
<br />MIMED IATE CAUSE (Flnal
<br />la) Cardiac arrest
<br />APPROXIMATE INTERVAL
<br />r
<br />onset to death
<br />immediate
<br />any ieirdhngtotheeeuleteted
<br />an Bnea
<br />Erdert oUNDEALYINGCAUSE
<br />(dlaeaw of In I pry That Initiated
<br />DUE TO, OR A9 A CONSEQUENCE OF:
<br />(c)
<br />1 onset lo death
<br />(
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />I ousel lod,0111
<br />XWAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />13 YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES G NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSEOF DEATH/
<br />❑ YES X]WO
<br />22c. PLACE OF INJURY -At home. term, street- lechtry, Office building, construction site. etc. (Specify)
<br />229. DESCRIBE HOW INJURY OCCURRED
<br />OF INJURY • STREET 4 NUMBER, APT. N0.
<br />CITWFOWN
<br />STATE
<br />21P CODE
<br />04#(0045.0 9( GNED (Mo., Day, Yr.)
<br />DATE OF 0.
<br />0.. Day. Yr.)
<br />d To the best 01 my knowledge, death occur ed at the lime, dale and place
<br />andd the cawe(s) staled. (Signelu a and Yale 1 •
<br />*DATE SIGNED (Mo., Day, Yr.)
<br />March 23,, 2006
<br />TOBACCO U5E CONTRIBUTE TOTHE DEATH? .14AS ORGAN OR T SSUE 0096010N BEEN CONSIDERED?
<br />316. TIME OF DEATH
<br />7`
<br />6:00 a
<br />PRONOUNCED DEAD (Mo., Day, Yr.) patt. TIME PRONOUNCEDDEAD
<br />March 11, 2006 10 :33 am
<br />mebes
<br />.time, ate � pta due to m exa anon andror investigation. inmyopfnion team 0(0011ed al
<br />e caws 1r ( nat eputy weandiltI' l
<br />�} ttle 1 , � , � �a I� �
<br />L, County Attorney
<br />'. WAS CONSENT GRANTED ?..
<br />Not Applicable 112641s NO ❑ YES K) NO
<br />❑YES 4.3 NO ❑ PROBABLY XI UNKNOWN ❑ YES CXNO
<br />t NAME, TITLE AND ADDRE550F CERTIFIER ( PHYSICIAN. CORONER'S PHYSICIAN 011 COUNTY ATTORNEY) (Type or Print) 231 South Locust Street
<br />Michelle J. Oldham, Chief Deputy Hall County Attorney, Grand Island. NE 68801
<br />280. DATE FILED BY REGISTRAR (Ma, Day. - -
<br />MAR 2 7 2006
<br />CERTIFICATE OF DEATH
<br />
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