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STATE OF NEBRASKA sa 6X YB m - a ; � 9 J :' > M' ) . IDS +s s .Wiraa8 . 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 12/1/2016 LINCOLN, NEBRASKA 201800712, STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY S. DOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1- > 8c. CITY OR TOWN OF DEATH (Include Zip Code) • Cairo 68824 1. FATHER'S -NAME (First, Middle, Last, Suffix) Manuel Rodriguez Martinez 412. MOTHER'S -NAME (First, Middle, Irene Rodriguez Rodriguez Maiden Surname) 9a. RESIDENCE - STATE Nebraska E 9d. STREET AND NUMBER >, 515 White Ave A m 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married Z ❑ Married, but separated j ❑ Widowed ❑ Divorced ❑ Unknown c 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. 8 (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION H ❑ Burial ❑ Donation E Cremation ❑Entombment j] Removal ❑ Other (Specify) 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY /TOWN 1/2 Mile East Of Sshauppsville Rd On Highway 2, Cairo STATE Nebraska ZIP COD 68824 tj 20. IF FEMALE: K ❑ Not pregnant within past year W ❑ Pregnant at time of death U © N pregnant: b pregnant within 42 days of death ▪ © Not pregnant, put pregnant 43 days to 1 year before death ❑ Vnknown if pregnant within the past year E 22a. DATE OF INJURY (Mo., Day, Yr.) O • January 21, 2016 22d. INJURY AT WORK? 22e DESCRIBE f NO ri H 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Leopoldo Rodriguez Martinez 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Mexico 7. SOCIAL SECURITY NUMBER 506 -35 -6196 Fib, FACILITY -NAME (If not institution, give street and number) 1/2 Mile East Of Sshauppsville Road 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street. Grand Island.' Nebraska CAUSE OF DEATHjSee instructions and examples) 11t. PART t Enter the chain or events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter termina events such as cardiac arrest, respiratory arrest or ventricular 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 disease or condition resulting a) Multiple Blunt Force Trauma Of The Head, Neck, Trunk, And Extremities APPROXIMATE onset to death Immediate [NTERVAL;. SequenllallY IisY conditions, d any, leading to the cause listed: on line a. onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury lust initiated the events retuning in death) LAST 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. 234, DATE O F DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) 2 TIME OF DEATH a a W E U z _ 3d. To the best of my knowledge, death occurred at the t date and place and due to the cause(s) stated. (Signature and Title) DUE TO, OR AS A CONSEQUENCE OF: b) 22b. TIME OF INJURY 05:30 AM 5a. AGE'. Last Birthday (YrS•) 43 9b. COUNTY Hall 21a. MANNER OF DEATH ❑ Natural ❑ Homicide E Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 5b. UNDER 1 YEAR MOS. 16a. EMBALMER - SIGNATURE Katie M. Smydra 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA DAYS ❑ Pedestrian Other (Specify) 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. OTHER ❑ Nursing Home /LTC ❑ Hospice Facility ❑ Decedent's Home lI Other (Specify)State Highway. 8d. COUNTY OF DEATH Hall Be. APT. NO. 9f. ZIP CODE 68803 14a. INFORMANT -NAME Lori Jo Martinez 16b. LICENSE NO. 1454 24c. PRONOUNCED DEAD !Mo., Day, Yr. January 21, 2016 3. DATE OF DEATH (Mo., Day, Yr.) January 21, 2016 October 6, 1972 6. DATE OF BIRTH (Mo,;Day, Yr,) Sc. CITY OR TOWN Grand Island 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Lori' Jo Davis 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) January 29, 2016 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? Driver /Operator E YES ❑ NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? E YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) State Highway IBE HOW INJURY OCCURRED The decedent was driving a vehicle that was struck by an oncoming vehicle that crossed the center line into prp Ant's ririving Jane ThP ripnpripnf'4 vishirtip wag ctrurk nls r the driver's cirhP rinnr 24a. DATE SIGNED (Mo., Day, Yr.) February 16, 2016 24b. TIME OF DEATH )I I I Approx. 05 :30 AM 24d. TIME PRONOUNCED DEAD 05:55 AM 24e. On the basis of examination and /or investigation, M my opinion death occurred at the time, date and place and due to the cause(s) elated. (Signature and Title) Sarah Carstensen, Chief Deputy Hall County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN ❑ YES E NO Not Applicable If 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Sarah Carstensen, Chief Deputy Hall County Attorney, 231 S. Locust, P.O. Box 367, Grand Island, Nebraska, 68802 28a, REGISTRAR'S SIGNATURE Ge 28b. DATE FILED BY REGISTRAR (MO,; February 17, 2016 9g. INSIDE CITY LIMITS ® YES ❑ NO