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<br />STATE OF NEBRASKA
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<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 OFiISSUANCE
<br />3/5/2021
<br />LINCOLN, NEBRASKA
<br />202102170
<br />r..
<br />SARAH BOHNENKAMP
<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 />1, DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />James Anthony Martinez
<br />4. CITY, AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />Y. SOCIAL SECURITY NUMBER
<br />508-60-2276
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (if Oat institution, give street and number)
<br />8816 Park View Blvd
<br />64
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient;.
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />1611656
<br />3. DATE OF DEATH (Mo; Da
<br />December 27, 2016
<br />Yr.)
<br />6. DATE OF BIRTH tido., Day, Yr.)
<br />November 6, 1952
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) I8d. COUNTY OF DEATH
<br />La Vista 68128 Sarpv
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Sarpv
<br />9c. CITY OR TOWN
<br />La Vista
<br />0 /Omnice Facifliy
<br />9d STREET AND NUMBER
<br />8816 Park View Blvd
<br />De. APT. NO.
<br />9f. ZIP CODE
<br />68128
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ 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) If wife, give maiden name
<br />Rita Marie Munoz
<br />11. FATHER'S -NAME (Firet, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Carmel Martinez Helen Cabrera
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 02/08/1971-04/05/1974
<br />14a. INFORMANT -NAME
<br />Rita Martinez
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />16b. LICENSE NO.
<br />CITY /TOWN
<br />Westlawn Memorial Park Crematory Grand Island
<br />16c. DATE (Mo„ Day, Yr.)
<br />December 30 2016
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />Livingston -Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions and examples)
<br />19. PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT .Mar terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary.
<br />IMMEDIATE CAUSE:
<br />a) Prostate Cancer, Metastatic To Bone
<br />IMMEDIATE CAUSE (Final
<br />disease or c4ndaion resllaing.
<br />In death);
<br />Sequentially Ilst conditions, if
<br />any, leading to the cause listed
<br />on linea.
<br />Enter the UNDERLYING CAUSE
<br />(disease pr injury that initiated"
<br />the events resulting in death)
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />17b. Zip, Code
<br />68803
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />4.5 Years
<br />onset to death
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />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 ® NO
<br />20. IF FEMALE:
<br />0 dm pregnant within past year
<br />❑ Pregnant at time of death
<br />0 Not pregnant, Out pregnant within 42 days or death
<br />0 Not pregnant, but pregnant 49 days to 1 year before death
<br />❑ Unknown if pregnant within the pest year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />0 .:Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?:.
<br />0 YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, tS
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />224. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 27, 2016
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 29 2016
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />05:15 PM
<br />234, Toth* best of my knowledge, death occurred at the time, date and place
<br />Ino des to Eta Cevee(e) stated. (Signature and Title)
<br />Clayton J. Hoberman, MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ® NO 0 PROBABLY 0 UNKNOWN
<br />ify)
<br />STATE ZIP CODE
<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 odourted at!
<br />the time, date and place and due to the cause(s) stated. (Signature and Tnli
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />21. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Clayton J. Hoberman, MD, 2919 S 101st St, Omaha, Nebraska, 68124
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES 0 NO
<br />28a. REGISTRAR'S SIGNATURE J6-
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />January 6, 2017
<br />
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