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<br />WHEN; THIS : 'COPY CARRIES THE RAISED :SEAL' OF THE ;STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE JA TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND , HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR YITAL RECORDS
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<br />DATE Dr ISSUANCE
<br />5/7/2019
<br />LINCOLN, NEBRASKA
<br />202305835
<br />RUSSELL FOSLER
<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 />nil. DECEDENT'S -NAME (First, Middle, Last,
<br />Maria Pilar. Nunez De Leon
<br />CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Suffix)
<br />Mexico
<br />7. SOCIAL SECURITY NUMBER
<br />345-92-5580
<br />Sa. AGO = Last SIi
<br />(Yrs.)
<br />66
<br />b. FACILITY NAME got lbsdtudon, give street and number}
<br />CHI H:ealth:St. :Francis
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Islami 68$03
<br />a. RESiDENCE:-STATE
<br />Nebraska !
<br />9d. STREET AND NUMBER
<br />203 West 6th Street
<br />Oa. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />Bb. UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />MATE OF DEATH (Mc., Day, Yr.) ,
<br />Apri125, 2019
<br />6. DATE OF RIRiH (Ms 1
<br />October 12,195.2
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient OTHER 0 Nursing Home/LTC
<br />ER/Outpatient 0 Decedent's Home
<br />Q DOA 0 Otter (Specify)
<br />9b. COUNTY
<br />Hall
<br />@c. CITY oR TOWN
<br />C3rand Island '
<br />:Manned, butseparatod 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER S -t AME ((first, Middle, ' Lasti, Suffix)
<br />Blas Nunez
<br />13 EVER IN (4)),.RMED FORCES? Give dtae'
<br />(Yes Nq, w till.) Int. S
<br />15. METHOD OI DtSPOSTnON
<br />Q Burial ❑ Donation
<br />o Cremation 0 Entombment
<br />:aItemovai ] OtheftSpecify)
<br />service if Yes.
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g'.INSIDE CITY LIMITS'
<br />® YEs ❑ NO
<br />10b. NAME QF: SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Elicea Leon Sedan
<br />i2 MOTHERS -NAME; (First, Middle, Malden Surname)
<br />Pantile Rodriquez
<br />14a. INFORMANT NAME,.
<br />Eliceo Leon Bedoita
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Ruiz
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Funerales lzquierdo
<br />17a Ft/HERALNOME NAME AND MA LINO ADDRESS (Street, Cfty or Town State)
<br />Alt "Faiths Funeral Home. 2929 S. Locust Street. Grand Island, Nebraska
<br />16b LICENSE NO.
<br />1495
<br />CIN 1 TOWN
<br />Moroleon
<br />RELATIONSHIP TO DEC
<br />pouse
<br />16c. DATE (MO D:ay, YT.)
<br />May 10, 2019
<br />CAUSE OF DEATH: (pee IrrstrucIlons and examples)
<br />18 PAST i Enter lila rdtafn of intents- diseases, injuries, or complication -that directly sainted the death. DO t*OT entertentnital orients such as cardiac anent,
<br />- reSpiraiary ar esf, of arui fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one Caus.zln a nee. Add adtlinonal Wbs 8 necessary.
<br />IMMEDIATE CAUSE;
<br />IMMEDIATE CAUSE (final a) Myocardial Infarction - Heart Attack
<br />disease or conditro
<br />ion resulting
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />Segmental/visaafA!gietarle, i b)
<br />ane leadfaefev:
<br />17b ,T1p Code
<br />68801;.
<br />APPROW01151(IERVAi
<br />onset to f lkth ...
<br />Immediate
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE. C)
<br />{disease Injury that initiated: • '
<br />the evenrereeulth>&in dea91) DUE TO, ORAS A CONSEQUENCE OF:
<br />tact::: d)
<br />1& PART 0. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Diabetes, Kidney Transplant, Pneumonia ,
<br />20 IF.FEMALE
<br />❑ Not pregnardwitiun past•;
<br />❑ PregnMd at Hine of death '
<br />❑ Not pregnaMrbut pregnant within 42 days of death
<br />© M pebut gtegnaut days to 1 year beton death
<br />UNnkegnaal; 43nown a pteynentwltilin the past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d.:INJURY AT WDRK?
<br />❑YE S {N0
<br />22e. DESCRI
<br />21a. MANNER OF DEATH
<br />® Natural 0 Numicide
<br />0 Accident ❑ Pending Investigation
<br />0 Weide ❑ Could rids ba FetaMdited
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />Q other (SpeeiM)
<br />onset
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />Q YES, ND
<br />21c. WAS AN AUTOPSY PE
<br />❑YES .151] r40
<br />ORMED7,
<br />21d. WERE AUTOPSY SINDMNiS AYAH;ABLE
<br />TO COMPLETE CAUSE:OF OEATH?::
<br />YES ONO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construedon site, etc. (Specify)
<br />INJURY OCCURRED
<br />22f. LOCATION uF INJURY STREET & NUMBEN, APT.NO.
<br />DOTE OF:DEATH (Mo., Day, Yr.)
<br />. DA
<br />ED (Mo., Day, Yr.)
<br />CITVi iOWr1
<br />STATE
<br />23c. TIME OF DEATH
<br />sit To tic ab$t of ,„y k,wa::+:cy:.,:*oath `J .L:*%:,2 s! tt N't„ Cats ±nr! . N. r
<br />the dause(s) stated. (Slgnatd re end Tile)
<br />25. DID TOB/1C: USE CO. TRIBUTE TO THE DEATH?
<br />❑ YES ❑ NO ❑ PROBABLY El UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />WY 6.2019
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />April 25, 2019
<br />?.t? i./C/DE
<br />24b. TIME OF DEATH
<br />04:42 AM
<br />N '
<br />24d lime PRoweticto DEW
<br />04:4? AM
<br />n- "-e bate* al e•nr.!sa1ke and+nr 1pvw ti 5ttnrt In nw.4aIMM deed) oeWted
<br />the time, date and place and due to the causes) stated. (Signature and iiia)
<br />h Carstensen, Hall County Attorney
<br />26e. HAS ORGAN.OR TISSUEDONATION BENN CONSIDERED?
<br />0 YES 1°i •
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sarah Carstensen :,Hall County Attomey, 231 S. Locust, Grand; slr. • Nebraska, 88801
<br />26b. WAS CONSENT GRANTED? T.
<br />Not Applicable If 26a to NO © YES'
<br />❑"i
<br />28b. DATE FILED BY REGISTRAR Dai, Yr.)
<br />May 7, 2019
<br />0-1
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