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<br />STATE OF NEBRASKA-
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<br />WHEN 11 -US 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 :OFISSUANCE
<br />12/27/2022
<br />iCOLN, NEBRASKA
<br />1, RECEDEN1 S: NAME (f=irst,.' Middle,
<br />Charles AguQar
<br />20230
<br />SARAH BOHNENKAMI
<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 />Last, Suffix)
<br />4. CITY:AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand; Island, Nebraska
<br />T. SOCIAL.,egoURrrY: NUMBER
<br />:07464443'
<br />b. FACILITY•NAME (If not Institution, give Street and number)
<br />3622 Arabian Circle:
<br />Sc.'.CITY OR TOWN OF DEATH (Include Zip Code)
<br />•
<br />Grand Islandt01
<br />9a RESIDENCE -STATE;
<br />Nebraska
<br />Itd. STREET;AND NUMBER:
<br />3:022 Arabian Circle
<br />Sb. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />❑ Married, but separated 0 Widowed j] Divorced 0 Unknown
<br />FATHERS;NAME (pif3t,,... Middle, Last,
<br />St iniey Muller
<br />Suffix)
<br />13. EVER IN U.S ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) Yes 04/28/1963-04/25/1966
<br />15., METHOD OF DISPOSITION.
<br />j Burial r❑� 3lona on
<br />`Cremation 0 Enton bmsnt
<br />Removal'" ❑Other (Specify)
<br />F
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />77
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER I DAY
<br />MOS.
<br />85 PLACE OFDEATf
<br />HOSPITAL ❑ title
<br />0 ER/Outpatient
<br />DAYS
<br />HOURS
<br />MINS.
<br />2217661
<br />3. DATE OF. DEATH
<br />December 11") 2022
<br />8. DATE OF I (Mo., Day, Vr )
<br />July 2, 194E
<br />OTHER 0 Nursing Home/LTC
<br />Decedent's Home
<br />0 DOA::: 0 Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand island
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />8f. ZIP CODE
<br />68801
<br />d�w r e t ITY iJNll
<br />YEs
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nstn
<br />14a. INFORMANT -NAME
<br />Lisa Flora Ortiz
<br />165. EMBALMER -SIGNATURE
<br />Daniel D Naranjo
<br />12. MOTHER'S•NAME (First,
<br />Carlotta Salinas
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Cemetery
<br />175.FUNERAL Home NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral'Home, 2929 S. Locust Street, Grand Island,; Nebraska
<br />1Sb. LICENSE NO.
<br />1071
<br />CITY ! TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See bstrut tyns and examples)
<br />14b. RELATIONSHIP TO DECEDENT..
<br />Daughter
<br />lec. DATE tl bipti . r ►
<br />Dace ?2 20;
<br />e: PART I. Enter the chain of everds• -diseases, injuries, or eompkeatlons•that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory amst, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines it necessary.
<br />',IMMEDIATE CAUSE:
<br />c0001ATECA10SE1FlO _ a)Metastatic lung cancer
<br />dlsagse or eond'ik(eht re$UItlk1tt ,:
<br />In anoint • .'...
<br />Sequentially list condition*.'.
<br />any,:Ieading to the atalae alete
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A' CONSEQUENCE OF:
<br />b)
<br />Enter owuNDERtYINO:CAUSE '1
<br />(disease or Injury that Initiated
<br />the events resulting in dean1) ' DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />TE'
<br />Nebraska.
<br />176 27pCode
<br />88801
<br />APP TR INTERVAit
<br />onsettodeath
<br />12 Months
<br />onset to death
<br />18 PARI II OTHER SIGNU LCANT CONDITIONS -Conditions contributing to the death btR nrs1 rssullil g in thsunderlying cause given in PART L
<br />Chronic obtlttuctive puimonary disease, hypertension, systolic congestive heart failure, coronary artery disease
<br />©:Not pregnelnlwlsllnl.aatyeer: .
<br />r Pragnala at tine at 4eirth ;; ..
<br />❑ ;NOt pregnant, but pregnatlt iNkMn 42 days of death:
<br />❑ Not pregnant, but pregnant 4a days to 1 year before; death
<br />❑ timsnewnN:pfYpnantflitthepastyear
<br />22a.: DATE OF INJURY (Mo ,Day, Yr.)
<br />22d. INJURY AT WORK
<br />❑Y5s ❑NO
<br />ri
<br />22f LOCATION
<br />,S
<br />0
<br />eM
<br />21a. MANNER OF: DEATH
<br />Natural. ❑ HOrOlcide
<br />❑ Accident ❑ pending Investigation ..
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />❑ 9riv5u/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />0 Other(Speciy)
<br />onset tFBROM
<br />onset death
<br />19. WAS liIP.DIOALRXAiNIN
<br />OR CORONER CONTACTED?
<br />❑ YES ® No
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />YES J NO
<br />21d. WERE AUTOPSY FINDINGS AVMI
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ( NO
<br />22c. PLACE! OF INJURYAt home, farm, street, factory, office building, construction site, etc.> pecI y);
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />OF INJURY .STREET 8 NUMBER APT.NO.
<br />23s. DATE OF DEATH (Mo., Day, Yr.)
<br />December 17, 2022
<br />cITYfTOWN;
<br />23b DATE SlONEC (Mo., Day, Yr.)
<br />Oaten ber'20, 2022
<br />TOMO be000* knovdedge, death occurred at the time, date and place
<br />0101 due to rita:c5uee(s) stated. (signature and Tale)
<br />Chad Vieth. MD
<br />23c. TIME OF DEATH
<br />05:40 AM
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d.•TIME PRONGIME Dt9AD
<br />2sa. do the beats of examination and/or Investigation, in my opinion tbaaitnsd ss
<br />*Clime, date and place and due to the causes) stated. (signature end )
<br />25 DID 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES NO
<br />27. NAM ; /TWANG ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />,4-11 67,111.44-4P-ilkinL4-117
<br />TOBACCO USECOMTRIBUTE TO THE DEATH?
<br />YES ❑ NO(PROBABLY ❑ UNKNOWN
<br />26b. WAS CONSENT GRANTED? ..>.
<br />Not Applicable if 26a Is NO, , ❑YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 23, 2022
<br />o
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