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STATE OF NE
<br />1. WHEN THiS 'COPY CARRIES THE RAISED BEAT OF THE STATE OF NEBRASKA,
<br />CER7i7ES THE BELOW TO EA 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 />_ =
<br />DATE OF?ISSUANCE
<br />�?
<br />10/6/2021
<br />SARAH BOHNENKAMI'
<br />LINC(yLN. NEBRASKA n
<br />�(016
<br />O
<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 2113172
<br />1 DECEDENT3NAAIE (First, Middle, Last, Suffix)
<br />2. SEX
<br />3.'DATE dF'LTEATH(Mt%,DayxYr.:ti:
<br />Julla Lucia VAIs
<br />Gonzalez
<br />Female
<br />August R2021
<br />4. CITY AND &.TATE C►R TERRITORY,
<br />OR FOREIGN COUNTRY OF BIRTH
<br />8e. AGE - Las1:i31rthday
<br />;UNDER 1 YEAR
<br />8c UNDER 1 DAY
<br />6. DATE OF BtRTN (Mo.,Day, Yr:)
<br />(Yrs-)
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />unknown, Unknown
<br />52;'
<br />Septerntt
<br />7. SOCIAL $ECURiTY NUMBER
<br />8a PLACE Of DEATH
<br />015-$9-9378
<br />HOSPITAL: Din lent OTHER Nursing Home/LTG Hospice Faa111ty 1.
<br />�-
<br />0
<br />8b. FACILITY4AME(Mnot Institution, give street and number)
<br />® moutpadent ❑ Decedenes Home
<br />m
<br />xE,
<br />CHI Health St. Francis
<br />❑ DOA ❑ Other (Specify)
<br />80 CITY QR, WOPOEATH (include Zip Code)
<br />8d. COUNTY OF DEATH
<br />Grand Island 68803
<br />Hall
<br />9a.'RESiDENCE STA E
<br />9b. COUNTY
<br />9c. CITY OR TOWN
<br />Nebraska
<br />Hall ,
<br />Grand Island
<br />9d. STREETAND NUMBER
<br />e: APT. NO.
<br />9f. ZIP CODE
<br />9g INSIDECriV LIMITS
<br />4115 E 2nd St
<br />68801
<br />W vEs ❑ No
<br />106 :MARrTAL STA7U$ AT TIME OF DEATH ® Married ❑ Never Married
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) R Wfe, give maiden name
<br />a
<br />Married, but separated ❑Widgwad ❑ Divorced ❑ unknown
<br />, Lazaro Hernandez Gonzalez
<br />m
<br />11 FATHER S NAME (First, Middle, Lit Suffix)
<br />12 M01F#ER'S-NAME (First Middle, Maiden Surname)
<br />Calixto Willa
<br />Clara Triao
<br />13, EVEix IN U,S. ARMED FORCES? Give dates of service If Yes.
<br />14a.INFORMANT-NAME
<br />14b. REI ATION i1P TO pECEDFAtT
<br />(Yes, No, or unk) No . "
<br />Lazaro Hernandez Gonzalez
<br />Spouse
<br />16. METHOD OF DISPOSITION
<br />18a. EMBALMER -SIGNATURE
<br />16b. LICENSE NO.
<br />16c. DATE„(Mo„ pay, Yr) »
<br />4
<br />Q Bu31a► ❑Doflation '''
<br />Katie M. Smvdra
<br />1454
<br />::
<br />August`$, X11:
<br />CrematitMl ❑Entombment
<br />❑Removal? 06her(specify)
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN $TATE
<br />u°
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17a.',FUNERAL;HpME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />1-711.24P Gode
<br />$
<br />All Faiths Furteral Home. 2929 S. Locust Street, Grand Island, Nebraska
<br />68801'
<br />CAUSE OF DEATH instructidAWathd examples)
<br />1 S. PART I. Enter the chain of events- -diseases, injuries, or complications.that directly caused. the death. 00 NOT enter terminal events such as cardiac arrest, APPROXIMATE,: INTERVAL
<br />'
<br />Tespkatory arrest, or ventricular ttbridation without showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a line. Add additional Urns If necessary. `
<br />IMMEDIATE CAUSE: onsatto death
<br />1MUIEDIAii GitlBEtFlnat ;; a)Suspe�ted carbamazepine overdose ; FIOarB
<br />disc a"Condltlorim.
<br />to death► DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br />Sequentially qct conditions, if b)Depression Weeks
<br />leading to the cause listed
<br />any,,it
<br />DUE TO, OR AS A CONSEQUENCE OF: onset to deadn
<br />..
<br />Erdar the UNPtrR. LYINti CRUSE :...
<br />' ..
<br />(efaaasa or irljurythat'inklilted
<br />..
<br />ath
<br />the events resulting in deem) DUE TO, OR AS A CONSEQUENCE OF: onset to deLAST
<br />d)
<br />1S. PARTW: OTHER SIGNIFICANT CONDiTION8ondidone contributing to the death but not resuitingin the underlying cause given in PART
<br />L :19. WAS MEDICAL FJCAMINER !i
<br />Hyjrtensioii, dill#tlteS
<br />OR CORONER COhITAC:TiD?
<br />®YES .• ❑ NO
<br />0 IF FEMALE:
<br />21a. MANNER OF DEATH
<br />21b. IF TRANSPORTATION INJURY
<br />21c. WAS AN AUTOPSY PERFQRMgD?
<br />®:Not pregnant wlmin pesLyear . `
<br />Natural ❑ Hotrjicida
<br />©Odver/Opsrator
<br />.
<br />❑ YES Nfl
<br />❑PregrenE at lima of dsattE
<br />Accident >'en8ing mvasdg
<br />Passenger
<br />❑^�T
<br />lRot pregnant but pregnant whhan 44 days of deem
<br />❑®Saleide
<br />rmirred`
<br />❑ Could not be detn
<br />© pedestrian
<br />21d. WERE AUTOPSY PINDW CS AifAILABL
<br />V
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Omer (Specify)
<br />TO COMPLETE CAUSE OF DEATH?
<br />UMmownHPre'll"within mepastyear
<br />❑YES El NO
<br />224 DATE OFtNJURY (Mtn, Day, Yr.)
<br />22b, TIME OF INJURY
<br />22c. PLACEOF INJURY A#home; farm, street, factory, office building, construction site. etc ($pa)
<br />Ai► US 22;:2021. '
<br />Unknown
<br />Nome
<br />to
<br />22d. INJURY AT WORK?
<br />220. DESCRIBE HOW INJURY OCCURRED
<br />[I YES ONO
<br />intentional self harm
<br />RY - STRT&NUMBR, APTAOCITiON22i fiOC0.TOSTATE Z!P IrDDLr
<br />.,
<br />1.5E n9$p04Grand Island Nebraska1
<br />°
<br />23a. DATE OF DEATH (Mo., Day, Yr.) .z
<br />Z August 22, 2021
<br />246. DATE SIGNED (Mo., Day, Yr.), 24b.,
<br />s
<br />TIME OF DEATH
<br />S
<br />23b DATE SIGNED (Mo. Day,.Yr.)
<br />o r '2 21
<br />23c, TIME OF DEATH:
<br />11:11 AM�,`c
<br />n- 24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d.,71ME
<br />PRONOUNCED DEAD
<br />3d Ta t1m beat of tiny knowMdge, death occurred at ma time, date end piaea
<br />" 24e. tin the basis of examination and/or hwestigadon, irEmy opinion Qaagt dstunyitt at
<br />g
<br />acid due to me nause(s) stated; jeignature and rntel
<br />tite tare, data and place and due to the cwss(s) std. (Stgeura afFit.Title):
<br />a
<br />Nicholas M Cox, MD
<br />a
<br />Q
<br />26• 0.10 TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />2tib. WAS CONSENT GRANTED?
<br />YES >� NO ❑PROBABLY UNKNOWN
<br />❑ YES NO
<br />NotAppticabla If!26618 Nfl
<br />tiATITLE AND. AVORESOF CER71FIER(Type or tint)
<br />N1 IChOlas M,C,oX, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />N
<br />October 5, 2021
<br />
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