|
°t tfi;4'i�ttttntz
<br />)));/,1t; (ttltiAryt,n
<br />cf�ill%IM
<br />1 1 t r c 11 I N AA) tit f h e 1 e III 4 r I 1 y.. C; , tet .,. t
<br />��1 (11aj ,,fl/r� %t�ggi liWi6S� )t�)�� i.)t4ef,)aaa„w `$�Ry IDAN',I. �4y ('&IA[sW >ia .flu, 4%�i yAwi�i`:' t��\fAt ����i $I4rjd5`�att ��iui)iirit.$ j��aJ�1S�ea s� f g��a l[s440`� ), Rt � QyYA�Mt:i ,i "1., qyf
<br />t�itFr�i5AI9�ilI.: �i � ..... � J i�i ! I� , �)1)�d9f�i( \ .,tal3
<br />1it"/Dj•1�j\,t,�\�p'(�,'I�Ifn�cct.,wMr»so0i
<br />Mrrt'�CI�^I�Jf9.?ll�i la gR/
<br />airs,
<br />waffd, --- skg4ttt�.Ylifller,1„;4 .ffivem T, ;,.....ti9S MItent•)........mZsrAoxr\e #r./..
<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
<br />DATE OFISSUANCE
<br />9/24/2019
<br />LINCOLN, NEBRASKA
<br />201906838
<br />RUSSELL FOSLER
<br />ASSISTANT 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 />Ceara -
<br />1. DECEDENTS•NAME (Fire!, Middle, Last, Suffix)
<br />Frank Rodriguez Jr
<br />CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY QF El
<br />1
<br />e
<br />2. SEX
<br />Grand Island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />806-2-5683
<br />Sb, FACILITY -NAME (If not institution, give street and number)
<br />CHI Health St. Francis
<br />TH
<br />ba, ACE - Last Birthday Sb. UNDER 1 YEAR
<br />Male
<br />bc, UNDER 1 DAY
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />tember 6, 2019
<br />tire.) MOS. DAYS
<br />59
<br />8a. PLACE QF DEATH
<br />HOSPITAL PITAL (D inpatient
<br />ria
<br />ER/Qulpstient
<br />❑DOA
<br />HOURS
<br />MINS,
<br />6. DATE OF SIR
<br />March 27 1
<br />9TH6R 0 Nursing HomdLTB
<br />Decedent's Home
<br />0 Other (Specify)
<br />ci Haggles Facility
<br />ac. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 88833
<br />9a. RESIDENCE.*TATE
<br />Nebraska
<br />Ii,d. COUNTY OF DEATH
<br />Hall
<br />Sb. COUNTY
<br />Hall
<br />Sc, CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />118 W. 13th Street
<br />Os. MARITAL STATUS AT TIME OP DEATH ❑ Married ❑ Never Married
<br />© Married, but separated ❑ Widowed ® Divorced 0 Unknown
<br />11. PATHER'S.NAME (First, Middle, Last, Suffix)
<br />Frank Rodriquez
<br />13 EVER IN U.S. ARMED FORCES? Give dates of service If Yee.
<br />(Ysv, No, of Urik) No
<br />16. METHOD OF DISPOSITION
<br />® Burial ❑ Donation
<br />9e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
<br />888Q1 151 vas 0 NO
<br />lob, NAME OF SPOUSE (First, Middle, Last, Suffix) If with, give maiden nem*
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Barbara Goodwin
<br />❑ Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />14a. INFORMANT -NAME r,
<br />Frank Rodriquez III
<br />16a. EMBALMER -SIGNATURE
<br />Ryan Redinger
<br />10th; LICENSE NO.
<br />1318
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />16c. DATE (Mo., Day, Yr.)
<br />SeDt¢mber 11, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Shelton Cemetery
<br />CITY / TOWN
<br />Shelton
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />O'Brien-Straatmann-Redinaer Funeral Home. 4115 Avenue N, PO Box 2344. Kearney. Nebraska
<br />17b, 7JpCode
<br />68847
<br />SAUSEQ ETH (See tnstruc Ions and examolesL,
<br />PART I. Enter the Chain Of egrets- dIseaata, Injuries, or complications -that directly caused fie death. Do NOT ante terminal events tuck as cardiac arrest,
<br />tyspiratory sweat, or ventriCiiisi fibrillation without showing the etiology. DO NOT ABBSE41ATE. linter only ori cause en a line. Add edddloAN lines N neteseary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE MINN a) Septic Shock
<br />disease or Condition resulting
<br />OWN
<br />aetlualiially Est condi ions, i•
<br />any. ieadtns to the souse iytd::
<br />on line..
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Morganella Morganti Infection
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />.Enter the UNDERLYING CAUSE c)Ceu+se Of Morganella Infection Unknown
<br />(dleeeMorinjury thid Initiated
<br />the event. moulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />APPROXIMATEINTERVAL
<br />onset to death
<br />1 Day
<br />19. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />History Of Pancreatic Cancer Anti Lymph©ma
<br />•
<br />20. iF FEMALE:
<br />0 Net pregnant within peat year
<br />0 Pregnant at time of death
<br />0 NEI pregnant, Lid Pregnant wehM 45 day.of death
<br />prsyrtant, iota Pregnant;4g cars tel 1 year gar
<br />ere death
<br />❑ Upkngwa N pregnant within the past year
<br />21s. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident ❑ Pending Investigation
<br />0 Suicide 0 ;mud net be determined
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />. fttJURY AT WORK?
<br />0YES 0NO
<br />22b. TIME OF INJURY
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />Irl vas ❑ hie
<br />21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />0 Drivenaperator
<br />0 Pesnger
<br />❑ YES NO
<br />as
<br />0 Awastrian
<br />0 txhartspeaifv)
<br />lid. WERE AUTOPSY PINDINQS AVAILABLE
<br />TQ COMPLETE CAUSE OF DEATHS
<br />vas 0 NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO.
<br />311. DATE OF DEATH (Mo., Day, Yr.)
<br />S• 9.-mber'6, 2019
<br />tib. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />_r • = 2 11! .7: CAM
<br />id. To the best of my knowledge, death occurred at the time, date and place
<br />.9 and due to the causes) stated. (Signature and Title)
<br />Patrick George; Woods, MD
<br />CITY/TOWN
<br />STATE
<br />4a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ZIP CODE
<br />SN. On the basis or examinatIon and/or Investigation, In my opinion death occurred at
<br />the time, date and plaits end due to the cauae(s) stand, (Signature and Tide)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ® NO 0 PROBABLY 0 UNKNOWN DYES ® NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Patrick.Geore Woods, MD, 2820 W Faidley Ave, Grand Island, Nebraska, 68803
<br />•
<br />28a- REGISTRAR'S SIGNATURE !
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES NO
<br />280. DATE FILED BY REGISTRAR (No., Day, Yr.)
<br />September 24, 2019
<br />
|