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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE&L,T”MD►h( MAN SERVICES, IT CERTIFIES �
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA T OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY r0 M%' A If Ec
<br />DATE OF ISSUANCE
<br />FEB 24 2012
<br />LINCOLN, NEBRA$K , -
<br />20200066
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<br />STATE OF NEBRASKA r DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />To Be CompletedlVerifled by: FUNE61___ DIRECTOR
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Ruben Moreno Lozoya
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo.,Day,Yr.)
<br />February 21, 2012
<br />4. CITY AND STATE OR TERRITORY, ORFOREIGN COUNTRY OF BIRTH
<br />U. AGE -Last Birthday
<br />6b. UNDER 1 YEAR
<br />Sc. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Mexico
<br />(Yrs.(
<br />50
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 5, 1961
<br />7. SOCIAL SECURITY NUMBER-
<br />603-18-4320
<br />Ia. PLACE OF DEATH
<br />nommaL: 0 Inpatient MIME! Nursing Horne/LTC 0 Hospice Facility
<br />6b. FACIUIY-NAME (if not Institution, give street and number)
<br />0 ER/Outpatient 0 Decedent's Home
<br />0 DOA ® Oer(Sp.ciy) Daughters home
<br />1208 Warren LAne
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68801
<br />8d. COUNTY OF DEATH
<br />Hall
<br />8a RESIDENCE -STATE
<br />Nebraska
<br />8b. COUNTY
<br />Dawson
<br />Sc. CITY OR TOWN
<br />Cozad
<br />6d. STREET AND NUMBER
<br />742 Locust St.
<br />6e. APT. NO.
<br />6f. ZIP CODE
<br />69130
<br />9g. INSIDE CITY UMITS
<br />® Yes 0 No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) N wife, give maiden name.
<br />Severiana Alvidrez
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Manuel Moreno
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Maria Lozoya
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, orunk) NO
<br />14.. INFORMANT -NAME
<br />Severiana Moreno
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16. METHOD OF DISPOSITION
<br />16a. EMBALM NA jtE
<br />16b. LICENSE NO.
<br />16c. PATE (No., Day, Yr.)
<br />pNreehedan MembntetM
<br />� /f'y//
<br />l• r�r• 3 2012
<br />® N ❑ � )
<br />iternov0ffieVelatorio
<br />16d. CEMETERY, CREMATORY THER LOCATION CITY/TOWN STATE
<br />San Jose,Calle 4th Norte, Delicias,chihuahUa,Mexiol
<br />17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Imam Cade
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska - . osetil
<br />To Be Completed by: CERTIFIER
<br />CAUSE OF DEATH (See instructions and examples)
<br />1e. PART I. Enter the fhh.OLBel le-dhNrss, Noire, es sompaertlar-Mn directly awed the death. DO NOT edea anMkw ensue each as cardiac arrest.
<br />APPROXIMATE INTERVAL
<br />respiratory meet, orvnerlcuterflamenco, without sh wlog the etiology. DO NOT ABBREVIATE. Enter only one came on ■ line. Add additional line M necessary.
<br />IMMEDIATE CAUSE:
<br />In setlk)TE CAUSE (Final / �t
<br />disease or condition resulting a) a �,r�" ��i .H -
<br />onset to deathIMMEDIA'- A
<br />/ L%`
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, If b)
<br />any, leading to the cause listed
<br />onset to death
<br />on linea DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />onset to death
<br />(disease or injury that initiated
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: -
<br />LAST
<br />d)
<br />onset to death
<br />16. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given In PART L
<br />18. WAS MEDICAL EXAMINER
<br />OR CORONER ACTED?
<br />0 YES NO
<br />20. IF FEMALE:
<br />ONot pregnant within past year
<br />215,MANNER OF DEATH
<br />Mural 0 Homicide
<br />21b. IF TRANSPORTATIONINJURY
<br />0 DriverlOperator
<br />21c. WAS AN AUTOPSY RFORMED?
<br />❑ YES Zo
<br />❑ Pregnant at Imp of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑un tnown it -pregnant wttidn the past year
<br />0 Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (SpecN7)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ❑ NO - -
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b, TIME OF INJURY
<br />m
<br />22o. PLACE OF INJURY -At home, lar,, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />221. LOCATION OF INJURY - STREET S NUMBER. APT. NO. CITY/TOWN STATE ZIP CODE
<br />kt
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 21, 2012
<br />Z
<br />.5'NE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />m
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<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />���-2i/t Y
<br />23c. TIME OF DEATH
<br />2:05 P.m
<br />110 r
<br />orero
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />t�
<br />B a
<br />12 7t
<br />23d. To the best of my edge, death occurred at the time, date and place
<br />to . (Signature and TIDO)
<br />Ak..-.
<br />n W z
<br />2 C C
<br />I°- a c`
<br />5 Is
<br />24e. On the basis of examination and/or investigation, In my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />26. DID TOBACCO E CONTRIBUTE TO THE DEATH?
<br />❑ YES NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE NAT O BEEN CONSIDERED?
<br />0 YES N NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, PHYSICIAN ASSISTANT, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />Ryan Ramaekers, M.D. 2116p,Faidley Ave., Grand Island, NE 68803
<br />I
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<br />28.. REGISTRAR'S SIGNATURE
<br />.0 •
<br />26b. DATE FILED BY REGISTRAR Wk., Day, Yr.)
<br />FEB 2 4 2012
<br />II'
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