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<br />STATE OF NEBRASKA
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<br />WHEN THIS DOPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELO
<br />sI, A TRUE COPYOF 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 :OFISSUANCE
<br />.12/21/2021
<br />LINCOLN, NEBRASKA
<br />�I�)}f1fii� illy fi(1'lA�iill (°V,6H�il i(((+yrreeNVs`',.
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<br />'14.11 n
<br />SARAH BOHNENKAMP
<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
<br />1.;DECEDENTS-NAM5. (First, Middle, Last, Suffix)
<br />Mark( ESCObar Hernandez
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Guatemala
<br />74 SOCIA€ S URITY'NUMBER
<br />51 fi 58-+4'110
<br />8a.AGE Last Birthday
<br />(Yrs )
<br />8b: FACILITY -NAME IV not institution, give street and number)
<br />CHI Health St. Francig
<br />rand Island 8880
<br />Ba RESIDENCE -STATE
<br />Nebraska
<br />9d STREET AND NUMBER
<br />115 E Charles St .
<br />Zip Code)
<br />61::.
<br />Sb. UNDER 1 YEAR
<br />MOS. DAYS
<br />84PLACE OF DEATH
<br />HOSPITAL NI btpatient
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS - MINS.
<br />21 17375
<br />S. DATE OP DEATK{(Mo,# flay: ,
<br />December 14,'2021
<br />OTHER 0 Nursing Home/LTC
<br />0 ER!Outpatient 0 Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />9b. COUNTY
<br />Hall
<br />Al. STATUS AT TIM E'OF iDEATH Married 0 Never Married
<br />Id,' but separa
<br />11 FATHERIAIAME (First,
<br />Manuel Escobar
<br />Wowed 0 Divorced 0 Unknown
<br />Iddie, Last, Suffix)
<br />13.' EVER IN US. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />16. METHOD OF DISPOSITIO
<br />Burial 0 Donatlor
<br />CremaN n © Entombment
<br />❑ Remover` ❑Other (Specify)'
<br />9c. CITY OR TOWN
<br />Grand Island
<br />lob. NAME OF SPOUSE (First,
<br />Maria Venegas
<br />14a. INFORMANT -NAME
<br />Maria Escobar
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Middle, Last, Si
<br />1i . INSID@ CITY LIMITS
<br />FTEs ❑ Na _'
<br />12. MOTHER'S_NAME (First, Middle, Maiden Surname
<br />Arnaditik7 Hernandez
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />16b. LICENSE NO.
<br />1439
<br />17a FUNERAL: HOME NAME AND MAILING ADDRESS (Street, City or Town,: Stets):
<br />Givingston•SondermannFuneral Home, 601 N. Webb Road, Grand Island, Nebraska
<br />CITY ! TOWN
<br />Grand Island
<br />14b RISATIONSITIP TOOEOEDEW
<br />S
<br />ISc. DATEIM0,, Day, Vf)
<br />(20".20
<br />20 '1
<br />CAUSE OF DEATH (See instructions and examples)
<br />lb.PART I. Enter the chain of l .nts- -diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or venirlcuisr fMrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMnxEolAtscAv(a) COVID-19
<br />Final
<br />disease or texamon reaultlair
<br />in
<br />}
<br />aecue lly Gat aondttlons, If
<br />aej leltdip tb.t a cauaetlptad
<br />ort lone a
<br />tithertoeW ERLVNGCAUSE
<br />(diseittifor in)arythM`Idltiated
<br />the events resulting In death)
<br />LAST
<br />1& PA
<br />ETN.
<br />*SkopI
<br />20. 1F FEMALE:.
<br />Not pregnant wit in pest year
<br />Pregnant at:Nms et ilenth
<br />❑ Nftt pregrdt, but pregnantxMhin 42 days of death
<br />f4pi.PregnaIlk but pregnant 42 days tc t year hetore death
<br />Pregnant wr
<br />€fi
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />'TATE
<br />Nebraska
<br />kTb ZIp Code :..
<br />$8803
<br />ath
<br />, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />NT CONDITIONS -Conditions contributing to the death
<br />221C *DATE OF;INJURY (Mo., Day; Yr.)
<br />22d. INJURY AT WORK?
<br />❑ YES ::.0NO:
<br />2
<br />NOF itiuRY-
<br />21a. MANNER OF DEATH
<br />® Natural Homicide >:
<br />❑ Accident 0 ➢ending Investigation
<br />0 Suicide 0 Could not be determined
<br />lut
<br />reittilfingbf,thbunderlying cause givi
<br />22b. TIME OF INJURY
<br />n PART I.
<br />21b, IF TRANSPORTATION INJURY
<br />Oyer/Operator
<br />:t. Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WAS
<br />AL EXAMINER
<br />MCONTACTED'? ..
<br />® NO
<br />21c. WAS AN AUTOPtSY PERFORMED?
<br />1g1
<br />❑ YES . NO .
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLEX 'CAUSE OF DEATH?
<br />❑ YES
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />tEET & NUMBER, APT.NO.
<br />23a DATE OF'DEATH (Mb. Day, Yr.)
<br />December 11, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 14 2021
<br />23c. TIME OF DEATH
<br />02:25 PM
<br />To'too seat of my knowledge, death occurred at the time, date and place
<br />attd dole to the:cause(s) stated. (Signature and Title)
<br />exander Kaganas, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME
<br />DEt
<br />24d. TIME PRONOUNCED DEAD
<br />24e.11n tits tlasfs of examination and/or investigation, In my opinion death *Urns at
<br />_. the tgne, date and place and due to the eause(s) stated. (S and.'(itt).
<br />26. DID'rOBACCO USE OONTR(BUTE TO THE DEATH?
<br />AS ;RI NO 0 PROBABLY 0 UNKNOWN
<br />27 HAIM TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Alexander.Kaganas, MD, 2621 W Faidley Avenue, Grand Island, Nebraska, 68803
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />26b. WAS CONSENT G N
<br />RA
<br />Not Applicable If 28a Is NO
<br />NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 16, 2021':
<br />
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