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am 44911N k II WNW xe Rifona ,l•. yr,g 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 12/27/2018 LINCOLN, NEBRASKA 2 0 C 9 0 0 8 1 VISSISTANT STATEREGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Pursuant to section 3C-2413, demands for notice which may affect the estate of the deceased are tiled with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Jose Jesus Galvan Gonzalez 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) November 30, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a, AGE - Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Mexico (Yrs.) 75 MOS. DAYS HOURS MINS. August 21, 1943 7. SOCIAL SECURITY NUMBER 565-02-9868 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health (rrrt'1a;'t:;nf 0 ER/Outpatient El Decedent's Home 0 DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Omaha 68122 8d. COUNTY OF DEATH Douglas 9a. RESIDENCE -STATE Nebraska < 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 2210 West Phoenix 9e. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married [3 Married, but separated 0 Widowed ❑ Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name ; Victoria Vasquez 11. FATHER'S -NAME (First, Middle, Last, Suffix) Jesus Galvan Rico 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Amparo Gonzalez 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Victoria Galvan 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION Ei Burial 0 Donation 16a. EMBALMER -SIGNATURE Nicholas D. Tank 16b. LICENSE NO. 1478 16c. DATE (Mo., Day, Yr.) December 18, 2018 ❑ Cremation ❑Entombment 0 Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Oakdale Cemetery Glendora California 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Aofel Funeral Home. 1123 W. 2nd, Grand Island, Nebraska 176. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 1$. 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, APPROXIMATE INTERVAL 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 8) A^.I'+p C.trnke disease or condition resulting onset to death Days in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if : b)Essential Hypertension any, leading td the cause listed on line a. - - onset to death Years - - DUE TO, OR AS A CONSEQUENCE OF: Einer the UNDERLYING CAUSE C) Acute Respiratory Failure Due To Neurological Failure (disease or injury. /hat initiated.. onset to death Days the events resuitingln death) < , DUE TO, OR AS A CONSEQUENCE OF: LAST; d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ® YES ❑ NO 20. IF FEMALE::. 0 Not pregnant within pest year ❑Pregnant at time of death 21a. MANNER OF DEATH ® Natural ❑ Homicide 0 Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO ❑ Not pregnant,, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year ❑ Suicide ❑Could not be determined ❑ Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑YES ONO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE W -.---_ 23a. DATE OF DEATil n tr.:o., Day, 1c; November 30, 2018 > ‘i _4.f. -A L :.,..,.:y : __f.. _ . _. T.T.=_= _' Y rc > E' ti I 23b. DATE SIGNED (Mo., Day, Yr.) December 18, 2018 23c. TIME OF DEATH 12:09 AM I i E a. a 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD < 0 o w i 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(a) stated. (Signature and Title) Erik Jacobson, .MD 'o' w i 2 0 p g 5 24e. On the basis of examination and/or investigation, the time, date and place and due to the in my opinion death occurred at cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES ❑ NO 0 PROBABLY El UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ® YES ❑ NO 26b. Not Applicable WAS CONSENT GRANTED? if 26a Is NO ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Erik Jacobson, MC, 6901 N 72nd Street, Omaha, Nebraska, 68122 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 19, 2018 28a. REGISTRAR'S SIGNATURE !��tc-e " �-,