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H F1 j77 's • WHEN TMS 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 4Cote DATE OF ISSUANCE 5/9/2016 LINCOLN, NEBRASKA 201901970 STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 16 02403 To be completed/verifted by: FUNERAL DIRECTOR 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Celia C Pedroza 2. SEX Female 3. DATE OF DEATH (Mo., Day, Yr.) April 24, 2016 4. CITY A`:D STATE CR TERRITORY, CR FOREIGN COUNTRY OF R!RTH 5a. AGE - Last eir'hday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATF OF 31RTH:(Mo., Day, Yr.) Mexico (Yrs.) 85 MOS. DAYS HOURS MINS. January 2, 1931 7. SOCIAL SECURITY NUMBER 508-42-3217 8a. PLACE OF DEATH HOSPITAL © Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatient 0 Decedent's Home 0 DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand. Island 68803 8d. COUNTY OF DEATH Hall 9a RESIDENCE -STATE Nebraska 1, 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 1308 E 6th Street 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LtMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑Married, but separated 0 Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Augustine R Pedroza 11. FATHER'S -NAME (First, Middle, Last, Suffix) Tomas Arroyo 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Candelatia Fuentes 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Augustine Pedroza 14b. RELATIONSHIP TO DECEDENT Husband 15. METHOD OF DISPOSITION ®Burial 0 Donation 16a. EMBALMER -SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE (Mo., Day, Yr.) April 28, 2016 ❑ Cremation 0 Entombment ❑ Removal 0 Other{Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 !.:. 1 CAUSE OF DEATL: ;See instructions and ox3.m^Ies) 14. 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, respiratory arrest, or ventrikalar 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 a)Acute Hypoxic Respiratory Failure disease or condition resulting APPROXIMATE INTERVAL onset to death Hours in deem) DUE TO, OR AS A CONSEQUENCE OF: Sequentially bat conditions, if b) Healthcare Associated Pneumonia any, terming to the cause: bated on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease Or injury; that initiated, the seems resulting in death) -<. DUE TOOR AS A CONSEQUENCE OF: LAST d) , onset to death Days onset to death onset to death 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Atrial Fibrillation Wth Rapid Ventricular Response, End-stage Renal Disease, Anemia Of Chronic Disease Diabetes Mellitus 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? DYES ®NO feted by: CERTIFIE N' 0000❑,yt:. 111 a a ns dm m o 8 1 s w m O F.! O 21a. MANNER OF DEATH E Natural 0 Homicide AccidentPending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO 0 0 0ourm 0 Suicide Could not be determined ❑ Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 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 ❑NO 22e. DESCRIBE HOW INJURY OCCURRED i22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) Audi 24, 2016 To be completed by CORONERS PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) April 26, 2016 23c. TIME OF DEATH 03:13 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Jay C. Anderson, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ® NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR DO ATION BEEN CONSIDERED? ❑YES a 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, N bra8803 28a. REGISTRAR'S SIGNATURE /[ - agog !_w J { .�/V( 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 28, 2016