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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 />4126/2021
<br />LINCOLN, NEBRASKA
<br />••••re 1 i ECEDENT s NAME, :(First, Middle,
<br />ull0 Sa)vador:: C)iarnui` Sr
<br />2.022()385
<br />SARAHBOHNENKAMP T
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Last, Suffix)
<br />CERTIFICATE OF DEATH
<br />4-CITYANDSTATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />El Salvador
<br />Ti -SOCIAL SECURrrY NUMBER
<br />610.16-8651
<br />5s, AGE Last Birthday
<br />(Yrs)
<br />68
<br />8b. FACIUT'f -NAME. (If not Institution, give street and number)
<br />E CHI Health St. Francis
<br />8c. CITY OR TOWN OF DEATH (Include zip Code)
<br />Grand island 68803
<br />9a. RESIDENCE -STATE
<br />.32
<br />Nebraska
<br />9d43REETAND NUMBER
<br />X22 I~
<br />8tITS:fteetNi
<br />6b, UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL IitilleOtiont
<br />ER/Outpatient
<br />0 DOA
<br />9b. COUNTY
<br />Hall
<br />v IOa, MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />2 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER'544AME (First,
<br />Jose David Peraza
<br />Middle, L
<br />Suffix)
<br />13- EVER IN U.S.ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit)} No
<br />u 15. METHOD OF DISPOSITION
<br />Q Burial : ; ❑Dor stlon
<br />)g) Cremation ❑ Entombment
<br />2 Q Retnotraf: 00ther (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />MINS.
<br />3, DATE OF DEATI4 Elio ,
<br />April 17, 2021
<br />y,Yr
<br />6. DATE OF B1RT#1(Mo Dajf,.Yr.)
<br />August 1.:1902
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />1Ob. NAME::OF SPOUSE irk*, Middle,
<br />Martha Cuevas
<br />112, MOTHER'S -NAME (First, Middle,
<br />Rosa Afnelia Chamul
<br />9f. ZIP CODE
<br />68801
<br />92 NSIDECiTturs)TS
<br />YES ❑.. NO
<br />14a. INFORMANT•NAME
<br />Martha Chamul
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />14b. RELATIONSHIP TO DECEDENT
<br />spouse
<br />16c. DATE(Mo.,;Day, Yr,)
<br />Aprit2tl, 201:
<br />CITY I TOWN
<br />Gibbon
<br />17a.. FUNERAL HOMENAME AND MA UNG ADDRESS (Street, City or Town. Stats)
<br />ASH Fai(hs'Funeral€Home, 2929 S. Locust Street, Grand Island: Nebraska
<br />CAUSE OF DEATH (dee ttistructlofls and examDles)
<br />€d 18. PART I. Enter the chain of events- .diseases, injuries, or complicationsahet directly caused the death. DO NOT enter 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 ans. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CA0.BElfipet a). Pulmonary. Fibrosis
<br />dtleasa or cotfdltlon retuddtg
<br />lauds)
<br />co Sequentially list conditions, If
<br />any,. leading to the cause listed
<br />E... thefI(> E TV)(oCAUSE
<br />(disease orin)uiy theetithlited
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)COVID-19
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />STATE
<br />Nebraska
<br />17040 Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />oneet.to death
<br />Days
<br />onset to death
<br />Weeks
<br />onset;todeath
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18 PART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing
<br />the death but
<br />resulting In
<br />0 underlying cause given In PART L
<br />IF FEMALE:
<br />:ErNot pregpetfi asiutt pitet ye ,
<br />❑ Pragnatltatdmoofdpol
<br />Nat pregigtnt, bWPregnant within 42 days of death
<br />St ❑':. Not pregnant, but pregnant gleays to1'year before death:.
<br />G , ❑:: Unkno n pregnantwi within the peat year
<br />RY. ,
<br />e
<br />224. DATE OF1NJU
<br />IMea., Day
<br />22d. INJURY AT WORK?
<br />e1 ❑ YES .Q ftl0
<br />22E.:L
<br />Yr.)
<br />21a. MANNEROF DEATH
<br />Natural 0 Homicide
<br />❑ Accident © Pamlinekwesdgedoe
<br />❑ suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION
<br />0 Driver/Operator
<br />❑ Passenger
<br />.❑ Pedestrian
<br />0 other (Specify)
<br />INJURY
<br />onset to death
<br />19. WAS MEDICAL EXAMINEft
<br />OR CORONER CONTACTED?
<br />O YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES NQ
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES ❑NO..
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY At Nome, farm, street,
<br />tory,; office building, construct! otr slte, 814. (> jl)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />TION >OFINJURY STREET S NUMBER, APT.NO.
<br />23a DATE OF DEATH (Mo., Day, Yr.)
<br />April 17, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Aunt 19.2021
<br />E
<br />0
<br />CITYITOWN
<br />23c. TIME OF DEATH
<br />03:43 PM
<br />TO the hast of my knowledge, death occurred at the time, date and place
<br />and due to thecaute(s) stated. (Signature and Title)
<br />Alexander Kapanas, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOU
<br />(Mo., Day, Yr.)
<br />ZERCODE ;
<br />24b. TIME OF DEATH'
<br />ICED DEAD
<br />Y4a:;On thegasis of examination and/or investigatien,In my °dee n.Aeath.ogcuMettM,:.:;....
<br />the ttnis, date and place and due to tae causes) sated. (Slgneture anhlitli►:
<br />28a. HAS ORGAN OR TISSUE DONATION SEEN -CONSIDERED?
<br />0 YES NO
<br />27, NAME, TITLE AND AbORESS OF CERTIFIER (Type or Print
<br />LleXander Kaganas, MD, 2621 W Faidley Avenue, Grand"r
<br />25,'DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES HO 0 PROBABLY ❑ UNKNOWN
<br />28a. REGISTRAR'S SIGNATURE
<br />land, Nebraska, 68803
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 28a is NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />April 21, 2021
<br />i
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