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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 OF ISSUANCE
<br />12/18/2020
<br />LINCOLN, NEBRASKA
<br />202104616
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<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 />CERTIFICAT
<br />20 17951
<br />Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. I
<br />. 1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Juan Elias Bazan
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo,, Day, Yr.)
<br />December 6, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />Brownsville, Texas
<br />(Yrs.)
<br />66
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />October 31, 1954
<br />7. SOCIAL SECURITY NUMBER
<br />452-13-2679
<br />8a. PLACE OF DEATH
<br />HOSPITAL0 Inpatient OTHER ❑ Nursing Home/LTC ©
<br />Hospice Facility
<br />8b, FACILITY -NAME (If not Institution, give street and number)
<br />107 S Pennsylvania Avenue
<br />0 ER/Outpatient ® Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Venango 69168
<br />8d. COUNTY OF DEATH
<br />Perkins
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Perkins
<br />9c. CITY OR TOWN
<br />Venancio
<br />9d, STREET AND NUMBER
<br />107 S Pennsylvania Avenue
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />69168
<br />9g, (NSIDECITY;LIMITS
<br />®Yips
<br />0 KO'
<br />los. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Sandra Marie Hardinq
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Elias Bazan
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Porfiria Rodriquez
<br />13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />14a. INFORMANT -NAME
<br />Sandra M Bazan
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Buda/ ❑ ODttatidn
<br />16a. EMBALMER -SIGNATURE
<br />Jason Tickle
<br />16b. LICENSE NO.
<br />1394
<br />16e. DATE (Mo., Day, Yr,)
<br />December 12, 2020
<br />] Cremation 0 Entombment
<br />❑ Removal ` ❑ Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Venango Cemetery Venancio Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Bullock -)-Ong Funeral Home, 409 Warren Avenue, PO Box 452, Grant, Nebraska
<br />17b. Zip Code
<br />69140
<br />CAUSE OF DEATH (See inatrHCtionS'and examples)
<br />15. PART I. Enter the chain of events- -diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE Mina/ :. a) Respiratory Failure
<br />omen or condition resulting
<br />onset to death
<br />1 Week
<br />In deattt? DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)Congestive Heart Failure
<br />any, leading to the cause listed
<br />on line e.
<br />onset to death
<br />2 Years
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c) Coronary Artery Disease
<br />(disease or injury that initiated
<br />onset to death
<br />4 Years
<br />the events resulting in death( DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)Diabetes Type 2
<br />onset to death
<br />14 Years
<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 Not pregnant within past year
<br />t«7 Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />'❑ Driver/operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY: PERFORMED?
<br />❑ YES 0 NO
<br />Q Not pregnant, butpragnent within 42 days of death❑
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ unknown if pregnant within the past year
<br />Suicide 0 Could not be determined
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OFINJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22t. LOCATIONIOF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To be completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 6, 2020
<br />To be completed by
<br />CORONER'S PHYSICIAN
<br />or COUNTY ATTORNEY
<br />ONLY
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 15, 2020
<br />23c. TIME OF DEATH
<br />09:00 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />23d. To the best of my knowledge, death occurred at the time, date and place
<br />end due to the cause(s) stated. (Signature and Title)
<br />Clifford Colglazier, MD
<br />244. On the basis of examination and/or Investiga Ion, in my opinion death occurred at
<br />thetime, date and place and due to the cause(s) stated. (signature and Title):
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES I® NO ' ❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />El YES ® NO
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Clifford COlglazier, MD, 945 Washington Ave.,
<br />PO Box 97, Grant, Nebraska, 69140
<br />28a. REGISTRAR'S SIGNATURE-)
<br />04-4a- l giti-' i' 'de
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 15, 2020
<br />
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