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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF DOUGLAS COUNTY, NEBRASKA, IT CERTIFIES THE
<br />DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE DOUGLAS COUNTY
<br />HEALTH DEPARTMENT, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />04/30/2020
<br />OMAHA, NEBRASKA
<br />2020069'76
<br />•
<br />ADI POUR
<br />HEALTH DIRECTOR
<br />DOUGLAS COUNTY HEALTH
<br />DEPARTMENT
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Alberto Tovar Regino
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 19, 2020
<br />4. CITY AND STA1
<br />OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Mexico
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />65
<br />UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />8. DATE OF BIRTH (MN 'Day, YL)
<br />February 22, 1955
<br />7. SOCIAL SECURITY NUMBER
<br />606.18-2893:
<br />8b, FACILITY -NAME (If not institution, give street and number)
<br />CHI Health Bergen Mercy
<br />8a. PLACE OF DEATH
<br />HOSPITAL El Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />0 Hospice Facility
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68124
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1607 W Grand Island Avenue
<br />9b. COUNTY
<br />Hall
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY UNITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Marded ❑ Never Married
<br />❑Married,butseparated ❑ Widowed 0 Divorced 0 Unknown
<br />1Ob. NAME OF SPOUSE (First Middle, Last, Suffix) If wife, give maiden name
<br />Anita Rodriguez Gaona
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Flavio Tovar Nochebuena
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Placida Regino Panfila
<br />13. EVER IN U.S. ARMED FORCES?
<br />(Yes; No, or link.) No
<br />16. METHOD OF DISPOSITION
<br />0 Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑ Removal Q Opti (Specify)
<br />Give dates of service If Yes.
<br />14a. INFORMANT -NAME
<br />Jorge Tovar Rodriguez
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. UCENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />180. DATE (Mo., Day, Yr.)
<br />April 23, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Hoy Kilnoski Funeral Home and Crematory
<br />CITY / TOWN
<br />Council Bluffs
<br />STATE
<br />Iowa
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Good Shepherd Funeral Home, 4425 S. 24th St., Omaha, Nebraska
<br />17b. ZIP Code
<br />68107
<br />CAUSE OF DEATH (See instructions and examples)
<br />O. PARTL Enteritis, chain prevents- -diseases, Injuries, or complications that directly caused the death. 00 NOT enter terminal events such as cardiac west,
<br />respiratory arrest or wnhicutor fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a IMe. Add additional lines U necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) covID-19
<br />disease or condition resulting
<br />la death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentialy9atcondltone,lt b)
<br />any, leading to the cause gated
<br />on line a.
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Weeks
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE C)
<br />Mem°, iNnn that *Aimed
<br />the events rasukiumg is deathl
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<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 ®NO'
<br />20.1F FEMALE:
<br />❑ Not pregnant within put year
<br />❑ Pregnant at time of death
<br />© Not pregnant. but pregnant within 42 days of death
<br />❑ Net pregthint, but pregnant 43 days tot year betas death
<br />❑ Uaknmtm x prepnantydthIn the past year
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION
<br />❑ Driver/Operator
<br />❑ Passenger
<br />❑ Pbutrlan
<br />❑ Oxer (Specify)
<br />INJURY
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDING$ AVAILABLE
<br />TO COMPLETE CAUSE OF DEA"?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />Q YES 0 NO
<br />22b. TIME OF INJURY
<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. CITY/TOWN
<br />STATE ZIP CODE
<br />J
<br />a
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />April 19.2020:
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Li April 23, 2020 03:19 PM
<br />E aO 3d. To the Inst of my knowledge, doth occurred at the Abe, date and place
<br />and due to the cause(s) stated. (signature end Title)
<br />Michaei J. Sanley, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES El NO ❑ PROBABLY 0 UNKNOWN
<br />265. HAS ORGAN OR
<br />❑ YES
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<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 ceuse(s) stated. (Signature and TSN)
<br />SSUE • ATION BEEN CONSIDERED?
<br />gl NO
<br />286. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Michael J. Sanley, MD, 7710 Mercy Rd, Suite #308, Omaha, Nebraska, 68124
<br />28a. REGISTRAR'S SIGNATURE
<br />286. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
<br />April 30, 2020
<br />l
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