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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 4/25/2017 LINCOLN NEBRASKA STATE OF NEBRASKA 201704181 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH ,CL ji 4 i l , s STANLEY S. OOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES • 17 05089 •'• fr w d tb n E 8 0 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Bonnie Jean Aguilar 4, air AND STATE OR:':r EfRRITORY, OR FOREIGN COUNTRY OF BIRTH Blair, Nebraska 7. SOCIAL SECURITY NUMBER 507. -34 -5982 8p. FACILITY -NAME (If:nottnstitution, give street and number) 1124 S. Cherry'St 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island: 68801. cc 9a: RESIDENCE- STATE ut:...:.. Nebraska x:. 9d. STREET AND NUMBER ;; 1124 S. Cherry St [08 MARITAL STATUS AT TIME OF DEATH 10 Married ❑ Never Married Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 0 11. FATHER'S -NAME (First, Middle, Last, Suffix) Harold Miller 19. EVER IN U.S. ARMED FORCES? (Yes, No or link:) NO 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment 0 a Removal Other (Specify) 5a. AGE - Last Birthday (Yrs.) 82 9b. COUNTY Hall Give dates of service if Yes. 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska IMMEDIATE CAUSE (Final disease or condition resulting • deathl :: "' • .,Sequentially h®t cen tlhione,:if any, leadiaato the..cause liateif on line a Eider the UNDERLYMIO CAUSE '::(disease or:iyury :tint intti6ie:it the v e :: t Bang to death) 20. IF. FEMALE :::: ❑ Not pregnant within plat year ❑ Pregnant at tiros of death p Note pregnant,) but prepriant wi hin 42 days of death ❑ 1ot pregnant, pregnant.. 17 days to 1 year before death u 0 ,„„ # ,A ir:p ig nan t lttiir: the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 2 INJURY AT :WORK ? ❑. YES ❑:NO 22b. TIME OF INJURY 23a. DATE OF DEATH (Mo., Day, Yr.) April 13: 2017 13b. DATE SIGNED (Mo., Day, Yr.) April 14. 2017 23c. TIME OF DEATH 03:30 PM 9d. To the best of my knowledge, death occurred at the tine, date and place and due to the cause(s) stated. (Signature and Title) Ja MD 25. DID TOBACCO use CONTRIBUTE TO THE DEATH? ❑ YES El NO ❑ PROBABLY ❑ UNKNOWN 1 28a. REGISTRAR'S SIGNATURE /V. _ / �`- 5b. UNDER 1 YEAR MOS: DAYS 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 8a. PLACE OF DEATH HOSPITAL 13 Inpatient 0 ER/Outpatient ❑ DOA OTHER ❑ Nursing Home/LTC Decedent's Home 0 Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand Island 9f. ZIP CODE 68801 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden n.me.: Trinidad J :Aguilar 12. MOTHERS -NAME (First, Middle, Gladys Reynolds 14a. INFORMANT -NAME Dru A Duerinq 16a. EMBALMERSIGNATURE Not Embalmed 3. DATE OF DEATH (Mo., Day, Yr.) April 13, 2017 . 6. DATE OF BIRTH(Mo., July 30, 1934 8d. COUNTY OF DEATH Hall 18b. LICENSE NO. Malden Surname) 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP :TO DECEDENT.:: Son 16c. DATE (Mo., Day, Yr.) April 14, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services: CITY / TOWN Gibbon STATE Nebraska 174. Zip Code 68801 CAUSE OF DEATH (See ins/ructions:andexamples) 18. PART I. Eider the chain of e:v rits -- diseases, injuries, or complications- that directly caused:the death. go NOT enter'tenninal events such as cardiac arrest, respiratory arrest, or ventridutar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause on a lino; Add additional lines 6 necessary. IMMEDIATE CAUSE: a) Progressive Metastatic Ovarian Cancer APPROXIMATE INTERVAL onset to death Years DUE TO, OR AS A CONSEQUENCE OF: b) onsetto:death:: DUE TO, OR AS A CONSEQUENCE OF: c) onset to death gyen s rasa . DUE TO, OR AS A CONSEQUENCE OF: LAST; ..... .. .. d) onset to.deat( 18. PART Ii. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. History Of Breast Cancer, History Of Factor V Leiden 5 Deficiency, Depression, History Of Deep Venous Thrombosis 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined ; 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian Other (specify) 26a. HAS ORGAN: OR TISSUE DONATION BEEN CONSIDERED? ❑ YES El NO 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES j I NO 21c. WAS AN AUTOPSY .P ❑ YES ® NO 21d. WERE AUTOPSY:::F.INDINGS AVAILABLE TO COMPLETE CAUSE Of DEATH? ❑YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24r. PRONOUNCED DEAD (Mo., Day, Yr. J 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and /or Investiga ion, 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 ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ja.ne;:■. McDonald, MD, 800 N Alpha Street, Grand Island. Nebra 0 28b. DATE FILED BY REGISTRAR :(Mo.,' Day, Yr.) :::::. April 19, 2017 CD