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<br />WHEN "' THIS ` COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS ie
<br />201806940 INTERIM ASSISTANT STATE
<br />R
<br />REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />9/13/2018
<br />LINCOLN, NEBRASKA
<br />11524
<br />Pursuant to ,ection 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at tie time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Maria Reyes Puente
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 27, 2018
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />55. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Grand island, Nebraska
<br />(Yrs.)
<br />83
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />January 6, 1935
<br />7. SOCIAL SECURITY NUMBER
<br />507-34-5714:
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />_
<br />8b. FACILITY -NAME (Knot Institution, give street and number)
<br />804 S. Curtis
<br />0 ER/Outpatient ® Decedent's Home
<br />❑ DOA ❑ :ihar(Specify_
<br />'dc. r.:11 Y GR (OWI, OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY.
<br />Hail
<br />CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />804 S. Curtis
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />We. MARITAL STATUSAT TIME OF DEATH 0 Married ® Never Married
<br />Married, but separated ❑ Widowed 0 Divorced ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />11. FATHER'S -NAME (First, Middle, . Last, Suffix)
<br />Manuel A Puente
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Juana Guererro
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link,) No
<br />14a. INFORMANT -NAME
<br />Carmen Luna
<br />14b. RELATIONSHIP TO DECEDENT
<br />Sister
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Patricia R. Curran
<br />16b. LICENSE NO.
<br />1092
<br />16c. DATE (Mo., Day, Yr.)
<br />August 31, 2018
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />-:
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska
<br />17b, Zip Code..
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />It. PART I. Enter the chain of events --diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE (INTERVAL'.
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Pancreatic Cancer
<br />disease or condition resulting
<br />onset to death
<br />Years
<br />in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:-••z.�.
<br />D�lr.r.,s,• f r:s: . -, re,.: J)
<br />any, leading to the cause listed
<br />on line a.
<br />- _ra
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(t&sease or injury that initiated'
<br />onset to death
<br />the events resultatgln death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST ;: d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Diabetes, Hypertension
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES © NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />0 Pregnant at time of deathPassenger
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident D Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0
<br />21c. WAS AN AUTOPSY PERFORMED?'
<br />❑ YES ®NO
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, OA pregnant 43 days to 1 year before death
<br />0 unknown if pregnant within the past year
<br />0 Suicide 0 Could not be determined
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK? : =
<br />❑YES ONO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />A- W
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 27, 2018
<br />i; g
<br />24a. DATE SIGNED (Mo., Day, Yr.) `24b. TIME OF DEATH
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<br />PZ
<br />1. i.1 z
<br />n(Mo..Jr 1T!'s'F (le fl°LTla
<br />23b. DATE SIONE.. Day.'. 123•:.
<br />September 10, 2018 I 02:49 PM
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<br />III E I a
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<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the wuse(s) stated. (Signature and Title)
<br />Jane A. McDonald, MD
<br />W z
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<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ®NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES II NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jane A. McDonald, MD, 800 N Alpha Street, Grand
<br />Island: Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE' "7
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 11, 2018
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