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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
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEP125031Y8F6OT .0E8ORDS
<br />12/27/1ISSUANCE 2 0 i a) 0 0 8 1 U RUSSELL E REGI
<br />SSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />SERVICES, VITAL
<br />LINCOLN, NEBRASKA
<br />Pursuant to section 5.!-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 the time of death.
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Jose Jesus Galvan Gonzalez
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 30, 2018
<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 />Mexico
<br />(Yrs.)
<br />75
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />August 21, 1943
<br />7. SOCIAL SECURITY NUMBER
<br />565-02-9868
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility
<br />Sb. FACILITY -NAME (0 not Institution, give street and number)
<br />CHI Hea:thl!r' s!ei
<br />CHI
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA ❑ Other(Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68122
<br />8d. COUNTY OF DEATH
<br />Douglas
<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 />2210 West Phoenix
<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 />CI Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAMEOFSPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Victoria Vasquez
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Jesus Galvan Rico
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Amparo Gonzalez
<br />13. EVER, IN U.S.: ARMED : FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Victoria Galvan
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />®curial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Nicholas D. Tank
<br />16b. LICENSE NO.
<br />1478
<br />16c. DATE (Mo., Day, Yr.)
<br />December 18, 2018
<br />❑ Cremation 0 Entombment
<br />❑ Removal : 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Oakdale Cemetery Glendora California
<br />17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />ADfel Funeral Horne. 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />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,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, dr ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines A necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) f1 n, .+P Ctr'*e
<br />disease or condition resulting
<br />onset to death
<br />Days
<br />in death) ;. DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially fist conditions, it ' b) Essential Hypertension
<br />any, leading to the cause Ibted:-'
<br />line
<br />onset to death
<br />Years
<br />on a.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Eller the UNDERLYING CAUSE C) Acute Respiratory Failure Due To Neurological Failure
<br />::-(disease or injury that initiated
<br />onset to death
<br />Days
<br />the events Mulling in 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 />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES 0 NO
<br />2O. IF FEMALE:
<br />0 Not pregnant within pest year
<br />0 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />Passenger
<br />❑
<br />21c. WAS AN AUTOPSY PERFORMED?ss
<br />❑ YES ® NO
<br />Q Not pregnant, but pregnant within 02 days of death
<br />Q Not pregnant, but pregnant 43 days to 1 year before death
<br />❑.:Unknown if pregnant within the past year
<br />❑ 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 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEA -n 0..o.,..-
<br />.:o., Day, Yr.;
<br />Noyember 30, 2018
<br />T
<br />2' ;iy
<br />_.. ... ,. __
<br />- . :.;:..7. - P �-
<br />SEC;Y
<br />I. z
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 18, 2018
<br />23c. TIME OF DEATH
<br />12:09 AM
<br />1
<br />o n t o
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />0
<br />ow
<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 />Erik Jacobson, MD
<br />w z
<br />o 2 p
<br />§
<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 0 NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />® YES 0 NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ® NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Erik Jacobson, MC, 6901 N 72nd Street, Omaha,
<br />Nebraska, 68122
<br />28b. DATE FILED BY REGISTRAR (MO., Day, Yr.)
<br />December 19, 2018
<br />28a. REGISTRAR'S SIGNATURE
<br />452-- /-"r s `-" `--i.
<br />
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