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<br />STATE OF NEBRASKA
<br />%/f411iflfffta\a ` ai/tirrgrptr\w
<br />lulllliy
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<br />ENTHIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A 'TUE COPY OP THE ORIGINAL RECORD ON FILE WITH THE NEBRA$K4 DEPARTMENT OF HEALTH AND
<br />•HUMAN$BRW E$, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATEt3:Flssraiv
<br />L1IVCOLA/, NEBR,AS
<br />202206557
<br />60,./Atifi evitiunketti
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />Middle, ,Lest, Suffix)
<br />CERTLFJCATE OF DEATH
<br />4' CITY AND'STATEilij.,TERRITORY,;OR FOREIGN COUNTRY OF BIRTH
<br />\San. Y5N
<br />O, .Cali
<br />la.
<br />SOCIAL.SEOURIT'r NUMBER
<br />573.78 584
<br />Sb. FACrL)TY-NAME ((#'not l
<br />!tc OITY O I N QAI t 2k7tl
<br />Grand island 68803
<br />tutien, give street and number)
<br />FRer(onal Medical:Centter
<br />Se AGE - Last Sirthday
<br />(Yrs.)
<br />73
<br />Sb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />Sa. PLACE OF DEATH
<br />ii PITALILI inpatient
<br />❑ ER/Outpatie
<br />DO&
<br />90STREeT 4iuD NU h4IEi l2 : _.
<br />201.7 W toilely Pat1i'R
<br />9b. COUNTY
<br />Hall
<br />be, MAR(TAt.STATUS"AT TIME OF-DEATN ® Married 0 Never Married
<br />Married tuft separated• { Widowed.0 Divorced 0 Unknown
<br />FATEER' 3I Kt1
<br />'ediV.1 f a)
<br />3;=OVERKILL AltMgt
<br />Suffix)
<br />ROES? Give.dates'of service if Yes.
<br />(Yes,
<br />40, .0 ;0416, X13/1.,2/1969-03/08/1971.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />2.2:.;
<br />3, DATE,OF DEATRt:(/1c4 lay Yr:
<br />July 4; ,2022 i"
<br />OTHER ❑ Nursing Horne/LTC
<br />nt ❑ Decedent's
<br />0 Other (Specify)
<br />IEd. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />1Ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife,
<br />Dora Alicia Caceres
<br />14a. INFORMANT -NAME
<br />Dora Alicia Ramos
<br />6a. EMBALMER'SIGNATURE
<br />Leslie M. Solt
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />'Central City Cemetery
<br />FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town;:Stete.)
<br />Soft Wagner Funeral Home,;'t507'17th Street, Central City, Nebraska
<br />Ifi; PART C. antertt}e''cliain
<br />etory_a
<br />itt
<br />IMMEOIA'j'E OAUSE fPEthiI
<br />cease or collditiaft resukfl
<br />in
<br />tce Pantlity .
<br />00.00:000.1*
<br />YES lip.;_.
<br />12 M:OTHERS4NAME (First, Midd)e, Malden S
<br />Maria .l„tlisa Ivarra
<br />16b. LICENSE NO.
<br />1398
<br />CITY /TOWN
<br />Central City
<br />1413. RELATII
<br />Spouse
<br />NT'
<br />1td. DATE (Ma.
<br />July 9, 202
<br />CAUSE OF DEATH (See €nstructlona
<br />nd examples)
<br />eases, injuries, or coinpiications•that directly caused the death. DO NOT enter terminal events such as cardiac arrest, -
<br />IEiation'without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines H neteseary..
<br />ED1ATECAUSE:
<br />mitts respiratory failure due to COVID 19
<br />$pr)iuentiasy i M• 50114
<br />gnY.::(eapiifp to Cw::cadssJ)F
<br />US TO, OR. AS A CONSEQUENCE OF:
<br />)Interstitial lung disease
<br />t0, OR AS A -CONSEQUENCE OF:
<br />Abuts kidney Injury superimposed on CKD
<br />TO, OR.ASA CONSEQUENCE OF:
<br />CONDITIONS -Conditions contributing to the death'
<br />:A
<br />K€lN
<br />RTE. (MC.;:
<br />21a. MANNER OF DEATH
<br />® Natural Haeiiteide
<br />0 Accident pending investipatIon
<br />0 Suicide 0 Could not be determined
<br />resulting in the underlying cause given In PART`I.
<br />22b. TIME OF INJURY
<br />22c. PLACE OF I,
<br />ESCRIBE HOW INJURY OCCURRED
<br />ems»
<br />,d. 22• LOCATION OR
<br />DOU
<br />ET & NUMBER, APT.NO.
<br />CITYm
<br />23.2. DATE OF DEATId'(Mo., Day, Yr.)
<br />•
<br />Jply 4 2D2
<br />23b.:DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Il ly
<br />6f,102;*:. 01:02 PM
<br />To;t le best of liirkhowiedge, death occurred at the time, date and place
<br />etdthecawe(s 'sieted. (signature and Title)
<br />Nielsen
<br />CarINTRiBUTE TO THE DEATH?
<br />SLY:.• UNKNOWN
<br />:N
<br />21b.IF>TRANSPORTATION INJURY
<br />DtI er/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE.AUTOPSY FINOlNGS AV
<br />TO COMP(.ETIIOALISI OF DEA1H
<br />0 YES
<br />UR. Y-Attlotne farm,:atreet, factory, office building, construct
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />x^4c; PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF: DEATH.
<br />24d. TIME PRONOUNCED DEAD.:::
<br />Rae. On ttet.besis of examination and/or investigatlon, In my opinion destit occurred et:
<br />the time, date and place and due to the cause(s) stated. (Signature abS NtIe): ..
<br />TO6 O . USE 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />YES : � NO PR013A 0 ❑ YES ENO
<br />IVIV 1TI «AtOfJ Ao12 8 of`C i 'nFIER (fype or Print
<br />yari0 Nl€lsen,'I A X533 P.rairiieview'St, Grand Island, Nebraska, 68801
<br />REGISTRARiS StG)
<br />26b. WAS CONSENT GRA
<br />Not Applicable If 26a Is NO
<br />28b. DATE FILED BY REGIST
<br />July 20, 2022
<br />R (Mo:, Day; Yr.)
<br />
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