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400., failitttta.k STATE OF NEBRASKA asl Mug; 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Melquiades M Reyes CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 7. SOCIAL SECURITY NUMBER 505 -02 -9192 8b. FACILITY -NAME (If nottnstitution, give street and number) Mexico 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 7/5/2017 LINCOLN, NESRASKA CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand. Island 68803 9a. RESIDENCESTATE 9b. COUNTY Nebraska Hall 9d, STREET AND NUMBER 422 East 1st Street 10a. MARITAL ST ATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Melquiades Reves 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Link.) NO 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation E Cremation ❑ Entombment ❑ Removal ;;❑ Other (Specify) 14a. INFORMANT -NAME Toni Lee Reves 16a. EMBALMER- SIGNATURE Katie M. Smvdra 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town . State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska . PART 1. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death, DO NOT enterterminel events such as cardiac arrest, piratory arrest, or vefridutar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only One cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Hepatocellular Carcinoma disease or condition resulting .st death] DUE TO, OR AS A CONSEQUENCE OF: equetttially list conditions, if b) any, • leading to the . cause listed on line a. Enter the UNDERLYING CAUSE (d85e onjuryl at ated3 the ise eve nts r i res ;t m d LASE 20. IF 3 0 Not pregnantwithin past year ❑ Pregnant at time of death ❑ Not pregnani, but pregnant within 42 days of death ❑ Not pregnant, taut ptygnant 43 days to 1 year before death ❑ Unknown if pregnantwithin the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT: WORK ? ] YES DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET NUMBER, APT.NO. S p o. E Iu J U 2 u Q O 0 U . DATE OF DEATH (Mo., Day, Yr.) June 23, 2017 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH June 23, 2017 01:17 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) KennethVette', MD Sa, REGISTRAR'S SIGNATURE �- C;'rr 20 1800540 STATE OF NEBRASKA - DEPARTMENT OF HEALTH! AND HUMAN SERVICES CERTIFICATE OF DEATH 5a. AGE - Last Birthday (WS.) 62 8a. PLACE OF DEATH HOSPITAL E Inpatient 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined CITY/TOWN Sb. UNDER ;1 YEAR MOS. DAYS ❑ ER/Outpatient ❑DOA 9c. CITY OR TOWN Grand Island Ob. NAME OF SPOUSE (First, : , Middle, Last, Suffix) If wife, give maiden name Toni Lee Cooper 1 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Zenaida Mota CAUSE OF DEATH (See instructions and examples) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 0 Pedestrian Other (Specify) 22c. PLACE OF INJURY -At home, farm, street, 26a. HAS ORGAN OR TISSUE e • ATION 25. DID TOBACCO USECONTRIBUTE TO THE DEATH? ❑ YES E NO 0 PROBABLY ❑ UNKNOWN ❑ YES El NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kenneth Vettel, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803 STANLEY S. OOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 9e. APT. NO. 2. SEX Male 8d. COUNTY OF DEATH Hall 16b. LICENSE NO. HOURS 1454 CITY / TOWN Gibbon 5c. UNDER 1 DAY STATE BEEN CONSIDERED? MINS. 9f. ZIP CODE 68801 OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 3. DATE OF DEATH (Mo., Day, Yr.) June 23, 2017 6. DATE OF BIRTH (Mo., Da December 2D, 1954 Yr 9g. INSIDE CITY LIMITS E YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) June 26, 2017 STATE Nebraska 17b. Zip: Code 68801 onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ENO 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? Driver /Operator ❑ YES ENO ❑ Passenger 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO actory, office building, construction site, etc. (Specify) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 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 [] 28b. DATE FILED BY REGISTRAR (lit June 28, 2017 APPROXIMATE onset to death 5 Months C) C) Cb 00