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11:a diZZ911 $t onA,. iS 18884$It:;eseaaa a t',iesp STATE OF NEBRASKA saw .:„azdd9yylii;RROiffs+. <3yh'�WAaBar+ :.tz1461.V WHEN THIS COPY CARRIES THE RAISED SEAL OF ; THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 10/13/2021 LINCOLN, NEBRASKA fr:'fA./�o/F.I4,f r, 202109008 1 U ASS STANT STATE REGISTRAR SARAH NENKAMP DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES 21 13418 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_ 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Richard Dean Aguilar 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) September 29, 2021 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Grand Island, Nebraska (Yrs.) 72 MOS. DAYS HOURS MINS. October 3, 1948, 7. SOCIAL SECURITY NUMBER 506-60-6862 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CH) Health Nebraska Heart 0 ER/Outpatient 0 Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Lincoln 68526 8d. COUNTY OF DEATH Lancaster 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET ANO NUMBER 220 E. 19th St 9e. APT. NO. 9f. ZIP CODE 68801 90, INSIDE CITY LIMITS ® Yes 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Deborah Webber 11. FATHER'S -NAME (First, Middle, Last, Suffix) Trinidad Joseph Aguilar 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Barbara Dean Hatcher 13. EVER IN U.S ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Deborah Aguilar 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑'Buda/ 0 Donation 16a. EMBALMER -SIGNATURE Stacie L Cook 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) October 6. 2021 bil Cremation ❑Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska for Other (Specify). , . 17b. Zip, Code 888{11 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- di , injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CALM (rinal a) Cardiopulmonary arrest diaaase or condition retaining onset to death 1 Week In death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)Non-healing amputation stump any,; leading to the cattle listed on line a. onset to death 1 Month DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Congestive heart failure (disease or injury that Initiated onset to death 6 Months the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d)Ischemic cardiomyopathy onset to death 6 Months 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Critical right lower extremity ischemia requiring above knee amputation 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES ® NO 20. IF FEMALE: ©: Not Pregnant within past year 0 Pregnant atom• of death❑ 21a. MANNER OF DEATH E Natural 0 Homicide ❑ Accident 0 Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? YES NO 0 Not pregnant, but pregnant within 42 days of death❑Pedestrian 0 Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year ❑ Suicide ❑could not be determined ❑ Other (Specify) 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES ❑ NO 22a, DATE OF INJURY (Mo, Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEUICALCERTIF5R ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) September 29, 2021 To completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) October 7, 2021 23c. TIME OF DEATH 03:23 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the beat of my knowledge, death occurred at the time, date and place and due td the cause(s) stated. (Signature and Title) Heidi Hansen, MD 24e. On the basis of examination and/or Investigation, in my opinion d►pth dddurred at the time, date and place and due to the cause(s) stated. (Signature end Title) -: 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ❑ NO 0 PROBABLY ® UNKNOWN 26a. HAS ORGAN OR ISSUE DO ATION BEEN CONSIDERED? ® YES ■ NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a Is NO ❑ YEs 51) NO 2t NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Heidi Hansen, MD, 7440 S 91st St, Lincoln, Nebraska, 68526 28a. REGISTRAR'S SIGNATUREC Thl 0.. , ' Cal- i C �� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 8, 2021