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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 6/13/2018 LINCOLN, NEBRASKA 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand island 68803 9a. RESIDENCE -STATE 9b. COUNTY Nebraska Hall 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Ofilia Arellano 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH San. Saba, Texas 7. SOCIAL SECURITY NUMBER 507 -38- 5315 b. FACILITY -NAME CHI: Health St. Francis 9d. STREET AND NUMBER 903 E 5th St Oa. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Ysedo Reyna 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.} NO 15. METHOD OF DISPOSITION El Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ira Other (Specify) IMMEDIATE CAUSE (Final disease or condition resulting n death) Enter the UNDERLYING CAUSE (disease tutnMOhat initiated the events fesulting in death) LAST. 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT:WORK ❑YES ❑NO .. w E v 2 u O l o p �28a. REGISTRAR'S SIGNATURE not Institution, give street and number) a) Pnuemonia STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 16a. EMBALMER- SIGNATURE Stacie L. Ruiz DUE TO, OR AS A CONSEQUENCE OF: Sequemiailylist twndtions, If b) any, leading to ine cause hated DUE TO, OR AS A CONSEQUENCE OF: c) DUE TO, OR AS A CONSEQUENCE OF: d) 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death ❑ JIM pregnant; but pregnant within 42 days of death ❑ Not pregnant; but pfegltet t 43 days to 1 year before death 0 U n knawnif pregnaet within the past year 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. 23a. DATE OF DEATH (Mo., Day, Yr.) June 6 2018 23b, DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH June 8, 2018 1 07:10 AM 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) John A. War#oner, MD 25. DID TOBACCO USECONTRIBUTE TO THE DEATH? ❑ YES El NO ❑ PROBABLY ❑ UNKNOWN 201804320 5a, AGE - Last Birthday Sb. UNDER 1 YEAR (Yrs.) MOS. - :DAYS 85 da. PLACE OF DEATH HOSPITAL © Inpatient 14a. INFORMANT -NAME Chi Avila 16d. CEMETERY, CREMATORY OR OTHER LOCATION Westlawn Cemetery 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Al) Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Couktnot be determined CITY/TOWN 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print John A. Wagoner, MD, 800 N Alpha Street, Grand Island, Nebraska, .:: ❑ ER/Outpatient ❑ DOA . CITY OR TOWN Grand Island 9e. APT. NO. 10b, NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Theodore Avila /.� STANLEY COOPER ASSISTA � STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 8d. COUNTY OF DEATH Hall 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Ramona Rivas 6b. LICENSE NO. 1495 CAUSE OF DEATH (See instructions and examples) 0 Pedestrian Other (Specify) 2. SEX Female 26a. HAS ORGAN ORTISSUE DONATION BEEN CONSIDERED? ❑ YES i°i NO 5c. UNDER 1 DAY HOURS CITY / TOWN Grand Island j ATE SIGNED (Mo., Day, Yr.) MINS. OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) 9f. ZIP CODE 68801 8. PART L Enter the ;chain of events-diseases, injuries, or complications -that directly caused the death, DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a lice. Add additional lines if necessary. IMMEDIATE CAUSE: 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Kidney Failure STATE ,24c. PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) June 6, 2018 6. DATE OF BIRTH (Ma; Day, Yr:..) August 21, 1 ❑ Hospice Facility 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT. Son . 16c. DATE (Mb, Day, Yr) June 12, 2018 STATE Nebraska 17b,Zip Code 68801 APPROXIMATE INTERVAL onset to death 5 Days onset to del onset to death 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO: 21 IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFQRMED? LJ Driver /Operator ❑ YES ®NO ❑ Passenger 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 N 22b. TIME OF INJURY 1 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24b. TIME OF DEATH 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 REGISTRA June 8, 2018 ZIP CODE ❑ NO (Ma &, Days Y