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NICUTZtlf STATE OF NEBRASKA WHEN ! THIS ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 1/17/2017 LINCOLN, NEBRASKA 1. DECEDENTS - NAME (First, Middle, Last, Suffix James Anthony Martinez 4. CITY:AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand,lslan d, Nebraska 7. SOCIAL SECURITY NUMBER 508 -60 -2276 fib. FACILITY -NAME (If not Institution, give street and number) 8816 Park View Blvd 8c. CITY OR TOWN OF DEATH (Include Zip Code) La Vista 68128 80. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 881E Par View Blvd 1Q MARITAL STATUS Ai TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, butseparated' ! ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Carmel Martinez 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 14a. INFORMANT -NAME (Yesi No or Unk.) Yes 02/08/ 971 - 04/05/1974 Rita Martinez 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE ❑ Burial ❑ Donation E Cremation ❑ Entombment ❑, ROM:Aral 0 Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State } Livingston- Sondermann Funeral Home, 601 N. Webb Road, Grand Island. Nebraska PARTI. Enter the chain of events - -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arreat, or VefltncuItr fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause on a fine. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final disease or condition resulting in'death) Settwereially rrst Conditions, if :! gib) any, teasing to the Cause hated' on line a. Enter the UNDERLYING CAUSE ( dlsease or injury that inhfeteil the events resultmg:in death) Not Embalmed DUE TO, OR AS A CONSEQUENCE OF: DUE TO, OR AS A CONSEQUENCE OF: C) DUE TO, OR AS A CONSEQUENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20. IF FEMALE: 0 Not pregnant within past year ❑ Pregnant at time of death ❑ ❑ Not Notpregna0Ottit pregnant within 42 days of death pragnani, kut p43 days to 1 year before death ❑ Unknown if pregnant vwthtn the past year 22a. DATE OF INJURY (Mo., Day, Yr.) d. INJURY AT?WORK/ OY ❑NO 9b. COUNTY Sarpy a) Prostate Cancer, Metastatic To Bone 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. v <. 0 23d. To the bestof my knowledge, death occurred at the time, date and place 2 C and due to the cause(s) stated. (Signature and Title) M uJ • s ! Clayton J Haberman, MD 23a. DATE OF DEATH (Mo., Day, Yr.) W ! Decembef 27, 2016 8 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH u z December 29, 2016 05:15 PM 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Memorial Park Crematory 201703866 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 5a, AGE - Last Birthday (Yrs.) 64 1Ob. NAME OF SPOUSE (First, kliddia Last, Suffix) if - 'ifa, give maiden nam. Rita Marie Munoz CAUSE OF DEATH (See instructionsrtd examples) 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA CITY/TOWN 25. DID TOBAC Z USE CONTRIBUTE TO THE DEATH? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN ❑ YES E NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Clayton J. Hoberman, MD, 2919 S 101st St, Omaha, Nebraska, 68124,, 264. REGISTRAR'S SIGNATURE /� _ cow"- Sb. UNDER 1 YEAR MOS DAYS 9c. CITY OR TOWN La Vista 9e. APT. NO. 1 12. MOTHER'S -NAME (First, Helen Cabrera 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 101 ate STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC E Decedent's Home ❑ Other (Specify) 8d. COUNTY OF DEATH Sarpy 164. LICENSE NO. Grand Island 9f. ZIP CODE 68128 21b, IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ pedestrian Other (Specify) STATE :4a. DATE SIGNED (Mo., Day, Yr.) Middle, Maiden Surname) 3. DATE OF DEATH (Mo., Day, Yr.) December 27, 2016 16c. DATE (Mo., Day, Yr.) December 30, 2016 onset to death ❑ YES E NO 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title). 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 28b. DATE FILED BY REGISTRAR January 6, 2017 ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT . Spouse STATE Nebraska 17b, Zip Code 68803 APPROXIMATE: INTERVAL onset to death 4.5 Years onset to deat onsettOdeath 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E Nf3 21c. WAS AN AUTOPSY PERFORMED? 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH ? ❑YES 0 N ZIP CODE ❑