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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />SEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OP:1$SUANCE
<br />7/18/2022
<br />LINCOLN, NEBRASKA
<br />202 2 05766`
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />1. psespeAVsAaaE (FUSt, Middle,
<br />Martha Cuevas;Vela
<br />STATE OF NEBRASKA;- DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATEOFDEATH
<br />Last,
<br />Suffix)
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Mexico
<br />T S:pCIAL SECt#RITY NUMBER
<br />6`f0418 5()29 "
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />75
<br />$b. FACILJTY.NAME (If not institution,'
<br />treet and number)
<br />613. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE Of DEATH
<br />!HOSPITAL. ❑ inpatient
<br />322 E8th: St
<br />Sc CITY OR TOWN OF DE aTH (Include Zip Code)
<br />Grand Is(atid 68801
<br />ga. RESIDENCE -STATE
<br />Nebraska .
<br />9d; .TREE.T R Nt)
<br />322E 8th: St
<br />❑ ERJOu patient
<br />DOA.
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />MBES€ .
<br />HOURS
<br />OTHER
<br />MINS.
<br />3. DATE OP DEATH (Mo:, Daly Yr ) r
<br />June 26, 2022.::'
<br />8. DATE OF BIRTti (Mo., Day, Yr.)
<br />January 19, 1947:
<br />Nursing Home!LT(
<br />® Decedent's Home
<br />0 Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Se. APT. NO.
<br />10a. MARITAL STATUSAT TIME OF DEATH ❑Married 0 Never Married
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />11. FATHER S•NFtME (Hest, Middle, Last, Suffix)
<br />Dario Cuevas
<br />10tH. NAME Of SPOUSE (First, Middle, Last,
<br />Julio Chamul
<br />13. EVER IN U.S ARMEo'FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />15 mrolODoiFOISPOSI. oN.
<br />❑,:But{a! JDonatton
<br />I Cremation [) Entombment
<br />O Removal ❑ Other (Specify)
<br />14a. INFORMANT -NAME
<br />Brioni Chamul
<br />6e. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />9f. ZIP CODE
<br />68801
<br />Suffix) If wife, give maiden natalae
<br />MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Aaria Vela
<br />Tab. LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />lie.:FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebi
<br />S. 18. PART 1, Etta
<br />respiratory
<br />IMMEDIATE CAUSE (
<br />41 Oka dr oixa oa resulting
<br />In death,
<br />ktt
<br />CITY ! TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See Instructions' nd example
<br />lin Of events- -diseases, injuries, or compiications.that directly caused the death. DO NOT enter terminal events such as cardiac arrest, -:
<br />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 />Fh1b) a) Cardiac Arrest
<br />Sequentially list conditions, If
<br />any.IeOdingto
<br />1114,0010101311114
<br />�1 onIiMa
<br />LS Entb the tJNDERL:YING CAUSE
<br />p (disease erinturynkattitillated
<br />the events resulting In death)
<br />M ,
<br />22F. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWNs'
<br />e 23a. DATE OF DEATH (Mo., Day, Yr.)
<br />June 26, 2022
<br />DE
<br />1#"Y tiMITA::
<br />14b. RELATIONSHIP TO DECEoeNT'<
<br />drandda 1phter
<br />16c. DATE Da)t, Yr.i
<br />June 29x2022;.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Malnutrition
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C) Ascites and Malnutrition
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d) Hepatocellular carcinoma
<br />STATE
<br />Nebraska
<br />170, 2±P Code..:;
<br />68801
<br />ROXBMATE INTERVAL
<br />Minut S
<br />onset to death
<br />1-2 Months
<br />deaati ; t
<br />th
<br />18. PART IL OTHER SHINW)CANT CONDITIONS -Conditions contributing to the death but not resulting in the
<br />Type 2 Diabetes Mellitus with complications, dysmotility of stomach
<br />20.IFPEMALE. i':
<br />Not pregnant:. within peat year
<br />Pregnant at dine of death
<br />❑
<br />0 Not pregnaNot'pregnent but pregnant within 42 days of death
<br />nt,"but pregnant 03 days to 1 year before death
<br />.,,.#lhBnrtwn if
<br />wIthIn the put year
<br />22a. DATE OF INJURY (Mo. Day, Yr.)
<br />22d. I
<br />WORK?
<br />iNO
<br />22e. DESC
<br />21a. MANNER OF: DEATH
<br />® Natural ❑ Homicide
<br />0 Accident 0 Pending investigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />denying cause given In
<br />21t ,1F TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />O Passenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />PART I. 19. WAS MEDICAL 5XAMINES
<br />OR CORONER CONTACTtEDy
<br />❑ YES/ ®NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ®NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABL
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />Ip6cify)>'
<br />22c. PLACE>OF INJURY -At home, farm, street, factory, office building, construction f
<br />IRE HOW INJURY OCCURRED
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Jiang 29 2022 .' 01:09 AM
<br />7$d
<br />77 the boar of/yknowledge, :death occurred at the time, date and place
<br />afl�d due to the Luee(s) ataied. (Signature and Title)
<br />Alberto Solache Jr, MD
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />P ODE
<br />24d. TIME PRONOUNCEO;DEAD. ;>:..:
<br />On the belts of examination and/or investigation, in my opinion death h trred fa
<br />the dine, date and place and due to the cause(s) stated. (Signature 8rd113tie):.'
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES ]•: la NO ❑.: PROBABLY 0 UNKNOWN
<br />27..NAMEOTTL ArlD ADCRESS OF CERTIFIER (Type or Print
<br />Alberto Solache Jr, MD, 2444 W Faidley Ave, Grand Island, Nebraska, 68803"
<br />26b. WAS CONSENT GRAMTED?
<br />Not Applicable If 28a is NO
<br />28b. DATE FILED BY REGIS
<br />July 11, 2022
<br />
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