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<br />NH4EN T 1$ ' COPY CARRIES THE RAISED SEAL OF MTHET TATE DF NEOMS101,
<br />:CERT, IFS THE -DOCUMENT BELOW TO BE A'TRUE' COPY ,OF THEF OfiA G*VAL
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS :OFFICE, WHICH /S THE LEGAL DEPOSITORY FOR t/ TAL REGARDS
<br />DATE 0F`ISSUANCE
<br />5/14/2020.
<br />• LINCOLN NEBRAS
<br />STATE OF
<br />202304219
<br />s
<br />ASSISTANT STATE REG
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />BRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1. DEOEDEN t` NAIV B (First, . Middle, Last, Suffix)
<br />.................._..............
<br />Ramirez
<br />•
<br />4.l jTYAND STATED*TERRITORY, OR FOREIGN GOUN
<br />MexlcD
<br />7' SOCIAL SE URITY:NUM8ER
<br />608424164
<br />9b FACILITY NAME(ifriotinstitutton, give street and number)
<br />CHI Health St. Francis
<br />9d:)T1r OR T01!lli OFOEATN (include Zip Code)
<br />Grand Is0add8
<br />9a. REliiOENCE. S1 t l'E
<br />Nebraska
<br />6b. COUNTY
<br />Hall
<br />9d. MAUI' AND NUM$ :R
<br />814 S Cherry;' t t
<br />CERTIFICATE OF DEATH
<br />OF BIRTH
<br />5a, AGE • Last
<br />(Yrs.)
<br />81.
<br />ret
<br />5b:UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />Ilei PLADE'DP DEATH
<br />i1O$P(TAL . Itkaatte t
<br />Q tit/Outpatient
<br />Q DOA
<br />1012 : MAR1TAi. B.D% AT TIME OF DEATH ® Manied 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11.MTHER'S'NAMB4INrpt, Middle, Last Suffix)
<br />indat Dib.; Ramirez
<br />MAIN U.L AffiktEtt`FORCES? Give dates of senate if Yes.
<br />(Yes, No or link.) No
<br />16. METHOD OF DISPOSMON
<br />Surat Q0400on
<br />Cremetittn [ Entombment
<br />QRentioval QOifei•.(Specly)
<br />9e Clrr oRTowN
<br />Grand Island
<br />2. SEX
<br />Male.
<br />5.UNDER1DAY
<br />HOURS
<br />3, DEA
<br />AsAt
<br />20
<br />6004
<br />0 Other Openly)
<br />1 ed DE
<br />COUNTY OF ATH
<br />Hall
<br />6e. APT. O.
<br />1Ob. NAME OF SPOUSE'(F1rst Middle, ', Last, Rink)B ialtlh gift
<br />Bianca Castaneda
<br />14a INFORMANT.NAME
<br />Blanca Castaneda•
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />122`MOTHER'S-NAME (First, Middle, MalanSwinatne)
<br />Jbsefina Ramirez
<br />1 .
<br />16d. CEMETERY; CREMATORY OR OTHER LOCATiI
<br />• Grand isiend City Cemetery
<br />17a, FUNERAL. HOME NAME AND MAILNNG ADDRESS (Street, City or Town, Stade)
<br />i111 F9lths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />14b. ItF„*TIC. ENE, 7Q:
<br />+�Vi6a
<br />oAUSE OF DEATH (See :mdtieeructiot and examples)
<br />13. PART I. Enter the chin of events- 41bNtat ass, Inhales, or compacetlont directly caused she death. lm NOT enter terminal wamass events web assweat
<br />• respiratory sweet, or ventricular Nmllatien without showing the etiology. DO NOT ABBREVIATE. Enter ony one cause on a line. Add ameEsnel eine aasebsary.
<br />. IMMECi(ATECAUSE: •
<br />a)Acute Hypoxic Respiratory Failure
<br />ONE -
<br />Sequentially list coni
<br />any, **Ono to tip c, te.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Respiratory Distress Syndrome
<br />ed -
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />11M6lrtba�!tRLYEDdxGAE;lE c)GCiVIb-19Viral Pneumonia Confirm
<br />(dle'einla ter hgltty:Ehat2td
<br />this scams resulting In demi)
<br />LAST'
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />i APPNO7MNATE INTERVAL
<br />1&; PART l6 DMIE S.GNI ICANT coNorONS-Conditions contributing to the death but nlat re4cNttng h ti
<br />20. IF.FEMAL$;:,. •
<br />A
<br />II'otprygnatiEvaddn poot.y
<br />0 Preghlametlimearaeaai
<br />flet ltegIW0 butptagnant vdthIn 4t hays if arm
<br />Q .
<br />Q Not prigmmt, but pregnant 43 days to 1 yea tater* Own
<br />Uplmowrl..E.freSnatd.Yaladn9nPig Po: . '.
<br />(MP4 Day, Yr.)
<br />22d. INJURY AT WORK?
<br />•
<br />QYES. :.}
<br />NO:•
<br />..
<br />2
<br />21a MANNER OF DEATH
<br />® NomadHornlcide
<br />0 Accident ©thndhlg ldvesagatton
<br />Q SaIWM Q Could real be datatmhhsh)
<br />22b. TIME OF INJURY
<br />22e. DESCRIBE HOW I
<br />STREET & NUNS
<br />23a"OATEOPOEATH (Mo., Day, Yr.)
<br />April 28, 2020
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />2020
<br />A
<br />u
<br />22c. PLACE OF INJIR#Y.At hontd IArnli 3beet, tackry, offlee
<br />inderying Gauss given In PART L
<br />21b.. IF TRANSPORTATION INJURY
<br />Q DI re"Op rater
<br />08 Pasenger
<br />© Padeat100
<br />0 OEherlsonwi)
<br />sea 'careiisivrr
<br />i onset la death
<br />h
<br />•
<br />la WA' MIEDMAL
<br />On coacutaavoratl
<br />0YES ®NO
<br />OCCURRED
<br />CITY 'OWN
<br />226. TIME OF DEATH
<br />02:08 PM
<br />of 15y Imewledge, death occurwd a the Ems, ate and plata
<br />due tOlhottsuse(s) sfatsd. (Sigatlsw and Ties)
<br />Shoat z Juneio, MD
<br />ATM/
<br />24ti DATE
<br />26a. HAS ORGAN OR Tissue DONS
<br />YES Nf#
<br />26 DIQ TOBAt:O USE CONTRIBUTE TO THE DE
<br />C S Nfl Q PROBABLY ©UNKNOWN
<br />27 •NAME,; TITLE AND ADDRESS CERT ER (Type or Print
<br />Sboalb24unelc, MD, 2820 W Faidley Aye, Grand island, Nebraska; 68803.
<br />EDmi.::oar. Yr..
<br />PRONOUNCED DEAD (Mo„ Dist Mr4 Sat Tess PaCirtic,
<br />AN ElbowsofananbhwonsaMor�htayopbYenaea6t'.
<br />iitba bath, date and place and &melba-gnsew waled.
<br />MtPd€
<br />EN
<br />
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