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WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTF ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R " fx WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISM"MV04-WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 200107573 JUL 2 0 2001 -' AsSRS LINCOLN, NEBRASKA HEALTHAND STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERV%M9VWA M-AMD SUPPORT VITAL STAB _= 01 0 7 5 0 3 CERTIFICATE OF DEATH - 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH (Month. Day Year) M Female Jul 6 2001 4 CI Y AND STA OF BIRTH Oran U.S.A. name country/ �rura�� Sa. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Abner. Day Yeah MOS. DAYS 1 5c. HOURS' MANS. n n n z X n y O s Be. PUKE OF DEATH � n c� n ' 505-76-8899 r" �. Bb. FACILITY - Name (Irnor Invapeor4 9" sesel and manbad St. Francis Skilled Care Nursing m N 8c CITY. TOWN OR LOCATION OF DEATH ed. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island Yes ❑X No ❑ 1-4 N co 9c. CrrI. TOWN OR LOCATION ( INSIDE CITY LIMITS Nebraska ' Hall Grand Island 1813 W. 6th Street 68801 19e yes %] Na ❑ -Ti O 12 ® MARRIED ❑ WIDOWED 11 NAME OF SPOUSE (C wile. 0Ae msjgar1 henna! afe.l IsvecM) White fSp"I I Irish His anic NEVER DIVORCED Agustin Escutia 14a USUAL OCCUPATION /Give kind of wd k d" alvirp most 14b KIND OF BUSINESS INDUSTRY b F -A O Cake Decorator 3:111 16. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Leo James Caffery Mary Margaret Nunez 16 WAS DECEASED EVER IN U.S. ARMED FORCES? _ 1%, INFORMANT - NAME _v! No F-a W 813 W. 6th Street Grand Island NE 68801 _aLLMDAWR - SIGNATURE 8 LICENSE. NO 21 a METHOD OF D19POSITION 21b DATE 21c. CEMETERY OR CREMATORY - NAME 092 ❑X eaw ❑Removal Jul 11, 2001 Westlawn Memorial Park FUNERAL E 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE El ❑Damao° Curran Funeral Cha el 3826 W. Stolley Park Rd. Grand Island NE 22b FUNERAL HOME ADDRESS (STREET OR F F.D. NO.. CRY OR TOWN. STATE ZIP) 3005 South Locust Street Grand Island NE 68801 2& IMMEDIA (ENTER ONLY ONE CAUSE PER LINE FOR (a). lb), AND (c)) Interval between onaet and death PART 1 lal r e DUE TO. OR AS A CONSEQUENCE OF: kllarval In A a ornM arid death C� (b) V� DUE TO, OR AS A CONSEQUENCE OF' - Interval on (a)o onsel(a)o death I OTHER SIGNIFICANT CONDITIONS - Codibons co IVitmAng No the death but rot related PART al IF FEMALE WAS THERE A N 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER? a (Ages 124 10-54) YeS NO 17 Yes o No X Yes No 264. 25b. DqE OF INJURY (Ado.. Day. Yr) 7C 26d. DESCRIBE HOW INJURY OCCURRED Accident Undabrmned � M Suicide Pending 26e. INJURY AT WORK 261. PLACE (1 INJURY % 1A home, farm. Wee!. fackory E Homicide lmv. bon Yee ❑ No ❑ olR6teBa ouw Soeenl'/ 27a. DATE OF DEATH (Ma. Day. Yr/ CAD 28b. TIME OF DEATH C 7 Sfs £ S� M 27p. DATE SIGN D (W.. Day. Yr) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD IW Day, Yr/ 28d. PRONOUNCED DEAD /Hour) Go $ F 4f July 9, 2 :10am M y< CCCCEEEEEJJJJ 6 M- 27d. To the beat of my k . death a red rt the deN and due to the 288. On the basis d examination and/or kwestgadon, in my opinion death occurred at cause(s) staled. C 7 and Tool a and TM1e ► 29. DID TOBACCO USE CONTFUSifflE TO THE DEAT 3D8 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? YES NO ❑ MOWN WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTF ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL R " fx WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISM"MV04-WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE 200107573 JUL 2 0 2001 -' AsSRS LINCOLN, NEBRASKA HEALTHAND STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERV%M9VWA M-AMD SUPPORT VITAL STAB _= 01 0 7 5 0 3 CERTIFICATE OF DEATH - 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH (Month. Day Year) Eileen Kathleen Escutia Female Jul 6 2001 4 CI Y AND STA OF BIRTH Oran U.S.A. name country/ �rura�� Sa. AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH (Abner. Day Yeah MOS. DAYS 1 5c. HOURS' MANS. Black Hills, South Dakota (YM Sb 46 May 21 1955 7. SOCIAL SECURnY NUMBER Be. PUKE OF DEATH HOSPI "®' Inpatient OTHER: R Nursing Horne ' 505-76-8899 ❑ ER OIAba sera ❑ Residence Bb. FACILITY - Name (Irnor Invapeor4 9" sesel and manbad St. Francis Skilled Care Nursing ❑ DOA ❑ DOW(Swr(y) 8c CITY. TOWN OR LOCATION OF DEATH ed. INSIDE CITY LIMITS 8e. COUNTY OF DEATH Grand Island Yes ❑X No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CrrI. TOWN OR LOCATION ad STREET AND NUMBER (InckmI gZip Code! INSIDE CITY LIMITS Nebraska ' Hall Grand Island 1813 W. 6th Street 68801 19e yes %] Na ❑ 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY le.¢. Malian. Mexican. Garman etc) 12 ® MARRIED ❑ WIDOWED 11 NAME OF SPOUSE (C wile. 0Ae msjgar1 henna! afe.l IsvecM) White fSp"I I Irish His anic NEVER DIVORCED Agustin Escutia 14a USUAL OCCUPATION /Give kind of wd k d" alvirp most 14b KIND OF BUSINESS INDUSTRY 115. EDUCATION ISP" only ho" grade comp) l c(wo,0v ft even imaredl E �rr1�t�{ry sacartwry 10 -121 College l0 0 5•I Cake Decorator 12 16. FATHER - NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Leo James Caffery Mary Margaret Nunez 16 WAS DECEASED EVER IN U.S. ARMED FORCES? _ 1%, INFORMANT - NAME (Yea no. or Iatk) IM yea give war and dares of services) No Agustin Escutia tgb INFORMANT MAULING ADDRESS ISTREET OR RF.D. NO.. CITY OR TOWN. STATE. ZIP) 813 W. 6th Street Grand Island NE 68801 _aLLMDAWR - SIGNATURE 8 LICENSE. NO 21 a METHOD OF D19POSITION 21b DATE 21c. CEMETERY OR CREMATORY - NAME 092 ❑X eaw ❑Removal Jul 11, 2001 Westlawn Memorial Park FUNERAL E 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE El ❑Damao° Curran Funeral Cha el 3826 W. Stolley Park Rd. Grand Island NE 22b FUNERAL HOME ADDRESS (STREET OR F F.D. NO.. CRY OR TOWN. STATE ZIP) 3005 South Locust Street Grand Island NE 68801 2& IMMEDIA (ENTER ONLY ONE CAUSE PER LINE FOR (a). lb), AND (c)) Interval between onaet and death PART 1 lal r e DUE TO. OR AS A CONSEQUENCE OF: kllarval In A a ornM arid death (b) V� DUE TO, OR AS A CONSEQUENCE OF' - Interval on (a)o onsel(a)o death I OTHER SIGNIFICANT CONDITIONS - Codibons co IVitmAng No the death but rot related PART al IF FEMALE WAS THERE A AUTOPSY 25. WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER? a (Ages 124 10-54) YeS NO 17 Yes o No X Yes No 264. 25b. DqE OF INJURY (Ado.. Day. Yr) 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident Undabrmned � M Suicide Pending 26e. INJURY AT WORK 261. PLACE (1 INJURY % 1A home, farm. Wee!. fackory 269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide lmv. bon Yee ❑ No ❑ olR6teBa ouw Soeenl'/ 27a. DATE OF DEATH (Ma. Day. Yr/ 28a. DATE SIGNED /Ab.. Day. Yr.I 28b. TIME OF DEATH S�3 �y 7 Sfs £ S� M 27p. DATE SIGN D (W.. Day. Yr) 27c. TIME OF DEATH 28c. PRONOUNCED DEAD IW Day, Yr/ 28d. PRONOUNCED DEAD /Hour) � T $ F 4f July 9, 2 :10am M y< CCCCEEEEEJJJJ 6 M- 27d. To the beat of my k . death a red rt the deN and due to the 288. On the basis d examination and/or kwestgadon, in my opinion death occurred at cause(s) staled. ° a the time, date and pace and due to the cause(s) staged. and Tool a and TM1e ► 29. DID TOBACCO USE CONTFUSifflE TO THE DEAT 3D8 HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? YES NO ❑ MOWN F_1 YES E N YES NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) !Type or Prinrl Ryan D. Crouch 800 Alpha St. Grand Island NE 68803 ua ncuprruw 32b. UAIt Yx&UtlY HEUlb I mAH (AM.. uay, Yr./ J(1! 11 2001