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<br />STATE OF NEBRASKA DEPARTMENT OF HEALTH AND HUMAN S*ERYtOE& . Jf�rlr' 4 V ; ,
<br />CERTIFICATE OF DEATH
<br />EIME7t - 3. E I OEAT MehSe4w► '.
<br />1. cacaasNrs-Ndis (Flydt, Weis, last. suffix)
<br />Enrique Ayala
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Venezuela
<br />7. SOCIAL SECURITY NUMBER
<br />g • 50611-6769
<br />ea. AGE -Last Birthday
<br />(We.)
<br />81
<br />Sb. FACILITY -NAME (if net institution, give street and number)
<br />Alegent Lakeside Hospital
<br />Sc. CITYOR TOWN OF DEATH (Include 21p Code)
<br />Omaha 68130
<br />RESIDENCE -STATE
<br />Nebraska
<br />Sb. COUNTY
<br />Hall
<br />Sb. WIDER 1 `lam,:
<br />Male June 11, i2Ot qp, s ;
<br />c(p: mom i DAY 0. DATEtF aiRTd 014;, oay y5.1
<br />MOS.
<br />DAYS
<br />Se. PLACE OF DEATH
<br />agaietanalg Inpatient
<br />O ERIOuipatent
<br />0 DOA
<br />Ed. CITY OR TOWN
<br />Grand Island
<br />1
<br />HOURS
<br />MINS.
<br />September 39;:19281
<br />OSLO Musing HomaILTC;
<br />O Decedent's Honor
<br />OBnNSped fy)
<br />414O13UNTY 'OF DEATH
<br />DeupIas
<br />❑ Mcrpih eFoot
<br />I
<br />ed. STREET AND NUMBER
<br />2418 Phoenix Ave.
<br />ee. APT. NO.
<br />so ai coos
<br />88803
<br />E,
<br />v
<br />m
<br />10a. MARITAL STATUS AT TIME. OF DEATH ® Berried O Never Married
<br />3 Married, brit separated i3 Widowed (J Divorced CI unknown
<br />10b. NAME OF SPOUSE (Phut Middle, Last, sutras) NMR, give maiden name.
<br />Virginia
<br />Lee Pierce
<br />,a. FATtlItrNiiuix it •i i +tea % •+.il ; ; i r r 4: Nfl rINS i ;' °"r"'t1, i
<br />Claria Y88tllit(; ' iasi : i
<br />: l ! ",
<br />Artpro Ayalaf � .
<br />s' Ne.100
<br />:M .ON$..::_
<br />19. EVER IN U.S. ARMED FORCES? Give dates or service N Yee.
<br />(Yes, No, or Oak.) No
<br />15. METHOD OF DISPOSITION
<br />Genet Oboesdon
<br />011t:rem.aoe tEetemhmem
<br />❑Remem Odm.gepnly)
<br />145. INFORNANT-NAME
<br />Virginia Ayala
<br />,ea. EMBALMER SIGNATURE
<br />Not Embalmed
<br />VW. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Autumn Hills Cremation Service
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Mid America First Call, Inc., 4425 S. 24th Street, Omaha, Nebraska for
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />LICENSE NO.
<br />CitYrrowN
<br />Omaha
<br />CAUSE OF DEATH (See Instructions and examples!
<br />is PART &EMmdte ymnareeeate_d.wew,Were" cempara"mm, that urged, nweda. death. 00 Nor eater termini swab saute catdbiiml.
<br />respiratory arrest, ervemrtuter RlaNtlime without ahon.g theaeolopy. 00 NOT POOH MATE. Einer only one maw on a IM. AddaadMoeel tines Ifmwewry.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final
<br />disease or condition resulting a)
<br />In death)
<br />Sequentially list conditions. N
<br />any, leasing to the cause listed
<br />on line a.
<br />(t7Gmoi C
<br />DDE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A�CCO�,NS�EQQUENCE OF:
<br />Earle the UNDERLYING CAUSE cl V " - D '-
<br />eteaee s eeup that initiated
<br />ated
<br />the
<br />DUE TO. OR AS A CONSEQUENCE OF:
<br />tiro aventar�Wng (n
<br />X
<br />b1Q
<br />tf'Wlf, i
<br />1SdDATE(IEo.l y --Uri",
<br />J}�ne l.3;.; :7Qd8
<br />STAT*
<br />Nebraska
<br />88107,
<br />.888011 `i ..
<br />rAPPROXRiATE INUOVAi. 11
<br />4
<br />10. PART II. OTHER SIGNIFICANT cONOmOpis ondluens cesllbuling to the death but net reaulati in Me ovilitlyentatitote gI hi PAHTL
<br />20. B FEMALE
<br />O Not pregnant within past year
<br />0 Pregnant at Uma el death
<br />ONot pregnant, but pregnant wittan42 days III death
<br />CI Not pregnant, but pregnant43 days to 1 yearbeRre death
<br />Uurdaown if pregnant' within the past year
<br />22a. DATE OF INJURY (Mo., Day. Yr-)
<br />22d. INJURY AT WORK?
<br />O YES ❑ No
<br />21a. MANNER OP DEATH
<br />Natural O Homicide
<br />O Accident 0 Pending Investigation
<br />O Suicide 0 Could not be determined
<br />21b. 5' TRANSPORTATION INJURY
<br />o
<br />O.Paeseh ger
<br />Q.Ildee4lan,
<br />O other (Speelfyl
<br />21c. WAS AN AUTOPSY ORMEIME -.... f ( •
<br />-
<br />0 YES ` }
<br />21d. WERE AUTOPSY' NGS AVAiimiL. i
<br />tocomoLBrE OFDBASMT_._ , i ._..
<br />OWES ERM° • ••/)_
<br />22b. TWE OF INJURY
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22a. PLACE OF INJURY -At home, rang street reFpry, office building, conebuetlon else Me. ($pacify) •
<br />22f. LOCATION OF INJURY - STREET a NUMBER, APT. NO, CITY/TOWN
<br />STATE
<br />246. TIME OF DEATH
<br />-204. DATE S
<br />23c. TIME OF DEATH
<br />dil ic$ place and due to the ca ) etatid.
<br />WM. REGETRAR'S SIGNATURE
<br />This certifies this document to be a
<br />Health Dept., Omaha, Nebraska. Cert
<br />of this green certificate are not legal copies.
<br />�r Mia with they area to the left. ReprOitictiOis° t :
<br />ti
<br />t 4 ..-
<br />s1 s1 ,.
<br />Registrar:
<br />
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