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<br />OF NEBRASKA
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<br />Y1410..''COPY ' CARRIES THE RAISED �t�`.i_ -_•
<br />F THE STATE OF NEBRASKA, ` IT
<br />CERTIFIES THE DOCUMENT BELOW TO Br A <TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />iRECO.ROS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />':DATE OFISSUAI.
<br />202208802
<br />STANLEY S. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Melqulades M. Reyes
<br />. CIVt ANDSTATEI
<br />Mexico
<br />'IE<RI 1TORY, OR FOREIGN COUNTRY OF BIRTH
<br />T. SOCIAL SECURI7
<br />506-02-9192.
<br />NU
<br />Sa.AGE-Lasa i3irtlday
<br />(Yrs•1
<br />62
<br />FACit.IYY NAME Tif Rot IRstit
<br />CHi!Heatth,.5t, Francis.
<br />tion,;g
<br />street and number)
<br />iC 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island ;88803 :.
<br />ea RESIDENCE: TATE
<br />Nebraska
<br />LL Sol. STREET AND NUMBER
<br />a, 422 East '1st Street
<br />9b. COUNTY
<br />Hall
<br />64• UNDER 1 YEAR
<br />MOS, DAYS
<br />8a. PLACE OF DEATH
<br />HOSPIITAL Inpatient
<br />❑ ER(Qu patient
<br />❑ DOA
<br />(lc. CI . OR TOWN
<br />Grand .island
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS MINS.
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 23,2017
<br />6. DATE OF BIRTH (Mo. Day, YT)
<br />OTHER 0 Nursing Home/LTC
<br />Decedent's Home
<br />❑ Other (Speelfy)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />19e. APT. NO.
<br />9f. ZIP CODE
<br />68801,
<br />9g. INSIDE CITYL1M1TS'
<br />® YES ❑ NO
<br />16a MARITAL STAMVSATTIME OF DEATH ® Married 0 Never Married
<br />IVlarrted, but separated!; ['IWidowed ❑ Divorced 0 Unknown
<br />11. FA'NER"S-NAME
<br />Melquiades Reves
<br />R sN U.S, ARMED FORCE
<br />(Yes, No, Or Unk<) ilia
<br />METHOD OF pisPt78JmN
<br />❑ Burial ❑ Donation
<br />t] C#emat on ❑ Entombment
<br />❑Removal Other 8Pecify)
<br />die, Last, Suffix)
<br />? Give date
<br />of service If Yes.
<br />10b. NAME OF SPOUSE TFIrsf, Middle, Last, Suffix) If wife, give maiden name.
<br />Tani Lee CooOer
<br />12. MOTHER'S -NAME (First, Middle,
<br />Zenaida Mota
<br />145. INFORMANT -NAME
<br />Toni Lee Reyes
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16b, LICENSE NO.
<br />1454
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State):'
<br />All faiths Funeral Home: 2929 S. Locust Street. Grand Island. Nebraska
<br />.PA. Ell
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See Instructions and examples)
<br />Maiden Surname)
<br />14b. RELATION PTO DECEDENT.;
<br />Spouse
<br />16c. DATE (Mo., Day, Yr.
<br />June 26, 2017
<br />Chattier events- -diseases, Injuries, or complications -that directly caudad the death. DO'NOT enterYennlnai 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 />IMMEDIATE CAUSE (Final
<br />or condition 115 ng
<br />kt deaths::.::
<br />segdentIalhi'hst plpliNtione,:t;:
<br />any gAdiMttOtitCaereeitefi'>'
<br />Enter.Inc UNDERLYING CAUSE
<br />(disease or Injury::ibat inWale I
<br />the events reivaing in darlth) :.
<br />a) Hepatocellular Carcinoma
<br />17b. Zi(t Coals
<br />68801
<br />APPROXIMATE INTERVAL;:.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />onset to
<br />DUE TO, OR AS A' CONSEQUENCE OF:
<br />C)
<br />,
<br />onset
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />onsetttldeatit
<br />PART H. OTHE
<br />IFICANTCON DITIONS-Conditions contributing to the death but not resulting in the underlying cause given In PART I.
<br />20.IF1MALE
<br />0 Not pftOnant WitiViVpiittyear
<br />Of ❑ Pregnantat time of deatr
<br />•y ❑ Pregnant, Opt pregnant within 42 days M death
<br />'4i ❑Not Pregnant{ put pregnant 43 days to 1 year before death
<br />.. [l Unknown a pr$pnant withinfthe pest year
<br />1 22a. DATE OF INJURY (Mo., Day, Yr.)
<br />72d..INJURY ATWORK/
<br />]YES ONO
<br />21a. MANNER OF DEA'T'H
<br />Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide ❑ Could dot be determined
<br />21b IF TRANSPORTATION INJURY
<br />❑ ttriver/Operator
<br />0 Passenger
<br />Pedestrian
<br />Exher (EWEN
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ] NO .:
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES 50 NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE"CAUSE OF DEATti1i ;
<br />❑ YES ❑ Nt1
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />• STREET ft NUMBER, APT.NO.
<br />a, DA .. QP DEATH (MO., Day, Yr.)
<br />Jttrte3 23 20317
<br />N
<br />CITY/TOWN
<br />2317 DATE S*4Ed (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />June 23, 2017 01:17 AM
<br />d: To ty* best of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />enneth Vette,, MD
<br />STATE
<br />24e. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH,
<br />ZIP CODE
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />728. GIG TOBACCO .USE C(: TRIBUTE TO THE DEATH?
<br />❑ MES'FIO ❑ PROBABLY ❑ UNKNOWN
<br />26a. HAS ORGAN OR TISSUE LIONA11013 BEEN CONSIDERED?
<br />YES 5ZINO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print)
<br />Kenneth Veftel, MD, 21=16 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />06 atftfagni°
<br />REGISTRA
<br />SIGNATURE
<br />26b. WAS CONSENT GRANTEDT;
<br />Not Applicable If 26a is NO - ❑.`i
<br />❑ ,No
<br />28b. DATE FILED BY REGISTRAR fab.+:
<br />June 28, 2017
<br />ay
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