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t... f�1Y(ZattMrtltl,s4 9ii l itaRaNAigei "., E9 piiiktAln?,`ru'IlIiii P tuktia,ItI a nedAta4ZtroafIIINI310/40/aa 11 d 1114'e'eIyeAt it • +;Jlfir,,"'''aa.,iiiifs$t€.tm�i4irAvit�..atWilli(iii-ix}".:u?'">1.,tyttwAraarw� 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 5/13/2021 LINCOLN, NEBRASKA 202201019 )60,14_11 OitottLAtikotot SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES IPursuant to section 30-2443, demands for notice which may affect the estate of the deceased are flied with the County court in the county where the decedent resided at the time of death, I .. _ ... ..ter.... 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Rafael Orozco-Barraza 2. SEX Male --- 3. DATE OF DEATH (Mo., Day, Yr.) May 3, 2021 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Mexico (Yrs.) 67 MOS. DAYS HOURS MINS. September 7, 1953 7. SOCIAL SECURITY NUMBER 561-92-9472 8a. PLACE OF DEATH HOSPITAL Kt Inpatient OTHER 0 Nursing Homs/LTC ❑ HOSpice Facility 8b. FACIUTY•NAME (if not Institution, give street and number) CHI Health St. Francis ❑ ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREETAND NUMBER 2105 N. Nashville Street Be. APT. NO. 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS RI YES p' NO 1oa. 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 Rita Cardoza-Barraza 11. FATHER'S -NAME (First, Middle, Last, Suffix) Rafael Orozco-Renteria 12. MOTHER'S -NAME: (First, Middle, Maiden Surname) Eva Barraza 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT•NAME . Rita C Orozca 14b. RELATIONSHIP TO DECEDENT Spouse 18. METHOD OF DISPOSITION 511 Burial 0 conation 0Entombment 16a. EMBALMER -SIGNATURE Laurie D. Sheffield 16b. LICENSE NO. 1397 16c. DATE,(Mo., Day, Yr.) May 8, 2021 Cremation Removal 0 Other (Specify) led. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME All Faiths Funeral NAME AND MAILING ADDRESS (Street, City or Town, State) Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See Instructions and examples) 13. PART I. Enter the chain of events- diseases, injuries, or complicationaehet directly caused the death. DO NOT enter terminal events such as cardiac west, APPROXIMATE respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on ■ line. Add additional linea If necessary. IMMEDIATE CAUSE: IMMEDIATECAt8E(Mnar a)Multi Organ/System Failure disease or condition remitting in dea6r) INTERVAL onset to death DUE TO, OR AS A CONSEQUENCE OF: sequentially list conditions, if b) Circulatory Failure any, leading to the cause listed on linea onset to death DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAME C) Cardiac Arrest (disease or iratay that initiated onset to death' the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) PEA onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: 0 Net pregnant within past year 0 PregMm at time of death- 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ AcciMm 0 Pending Investigation 21b. IF TRANSPORTATION INJURY <❑ Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES NO ❑. Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days tot year beforedeath ❑: Unknown If pregnant within the past year Suicide ❑Could not be determined 0 Pedestrian 0 Other (specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 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 ❑ N0,_ 22e. DESCRIBE HOW INJURY OCCURRED 221. LOCATION OF INJURY STREET b NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE k01 23a. DATE OF DEATH (Mo., Day, Yr.)24a. May3,2021 Z2G DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH o' 23b. DATE SIGNED (Mo., Day, Yr.) May 4, 2021 23c. TIME OF DEATH 05:15 AM r 46e -Z' 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 0 Iii 2 23d. Toth Wet of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (signature and Tale) Ali H Osman, MD 0 W o g § ~ § 6 24Pawned. On the basis of examination and/or investigation, in my opinion death Pawned at the tine, data and place and due to the causes) stated. (Signature and Title)12 26. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ❑ NO 0 PROBABLY ® UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ' ❑ YES 0 NO', 27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Ali H Osman, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803 28x. REGISTRAR'S SIGNATURE� .8 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 10, 2021CAD