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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND H MAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE 11(EBM KA,pIEPARTME'111T,gF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VI'.R€C'bRDS, ;,
<br />DATE OF ISSUANCE
<br />11/04/2010
<br />LINCOLN, NEBRASKA
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<br />HUMAN'SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES',
<br />CERTIFICATE OF DEATH
<br />t0 03121
<br />To be completed/verified by: FUNERAL DIRECTOR I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Frances Mary Salinas
<br />2. SEX c . ,
<br />Female. * ,: ;
<br />/3./DATEOF DEATH.(Mo., Day, Yr.)
<br />- -,October 31, 201.0
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. 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 />70
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS. '
<br />August 7, 1940
<br />7. SOCIAL SECURITY NUMBER
<br />507-54-4524
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />8b. FACILITY -NAME (if not Institution, give street and number)
<br />Saint Francis Medical Center
<br />0 ER/Outpatient 0 Decedent's Home
<br />❑ DOA ❑ Other(Specify)
<br />8c. CITY OR TOWN 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 />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />1121 N. Webb Road
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY LIMITS
<br />® YES 0 NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />❑ Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden name
<br />Alejandro Salinas
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Frank Guerrero
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ernestina C Cantu
<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 />Alejandro Salinas
<br />14b. RELATIONSHIP TO DECEDENT
<br />Husband
<br />15. METHOD OF DISPOSITION
<br />® Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Gerald Quandt
<br />16b. LICENSE NO.
<br />1143
<br />16c. DATE (Mo., Day, Yr.)
<br />November 4, 2010
<br />❑ Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Westlawn Memorial Park Cemetery Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />17b. Zip Code
<br />68803
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER II
<br />18. 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 Tines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Hemorrhagic Cerebrovascular Accident
<br />disease or condition resulting
<br />onset to death
<br />Hours
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)Atrial Fibrillation
<br />any, leading to the cause listed
<br />on line a.
<br />onset to death
<br />Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that Initiated
<br />onset to death
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART 1.
<br />Diabetes , Hyperlipidemia, Hypertension, Chronic Anticoagulation
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />0 YES ® NO
<br />20. IF FEMALE:
<br />® Not pregnant within past year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑Accident ❑Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ❑ NO
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but 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,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER I
<br />ONLY
<br />?3a. PTF OF DEATH (Mo., Day, Yr.)
<br />October 31, 2010;
<br />`
<br />s Z
<br />24a. DATE SIGNED IMo.. Day. Yr.(
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 2, 2010
<br />23c. TIME OF DEATH
<br />04:53 PM
<br />V. = k Y
<br />Ea.< Z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Jay C. Anderson, MD
<br />`o' w i O
<br />2 V p
<br />~ u
<br />24e. On the basis of examination and/or Investig tion, 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 0 NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />I Not Applicable if 26a is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, HYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY A##TORNEY)
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />(Type or Print)
<br />28a. REGISTRAR'S SIGNATURE Is.� _
<br />281,. DATE FILED BY REGISTRAR (Mo., Day, Yr.) L
<br />November 2, 2010
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