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STATE OF NEBRASKA
<br />JJPdmT 2!..lQ067V,sogitAN�s tbtri9Yftt:fo MMttyl filww.a ��rrMih4hitwS,
<br />WHEN %HIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />ECA TRUE COP;Y OF IVE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN` SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORYFOR VITAL RECORDS
<br />DATE OP ISELt4 E
<br />11/1.5/2023
<br />LINCOLN, NEBRASKA
<br />11.'DECEDENT S•NAME (FIrst,
<br />tebarl < . Velasco
<br />4. CITY AND $T
<br />Midi
<br />SARAH BOA
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH,
<br />202306725 AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />Last, Suffix)
<br />t TERRITORY,OR FOREIGN COUNTRY OF BIRTH
<br />Mexico
<br />7.3DClAL SE.C.UIMTY<I
<br />$BER
<br />806-43 5878 _.
<br />Sb. PAO'JTY}NAME {SHIM l ed
<br />110E 6th Street
<br />aa, AGE - Last Birthday Sb UNDER 1 YEAR
<br />(Yrs.)
<br />52:::.
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOS) ITAL. Q Inpatitfnt
<br />.'0 ER/Outpatient
<br />❑ DOA
<br />2. SEX
<br />Male
<br />Sc. UNDER) DAY
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Mo.,
<br />March 24‘,::2023
<br />9 DATE OF BIRTH (Mo., Day, Yi.)
<br />OTHER 0 Nursing Hard:'
<br />❑ Decedent's Noma
<br />Other (Spt0101)110 E BUt Strfet
<br />1.
<br />FacIDM
<br />32
<br />CITY OR TOWN OF DEATH ()nclude tip Code)
<br />Grand Island (1
<br />9a. RESIDENCE -STA"
<br />Nebraska
<br />9d STREETmD. NUMBER
<br />526 Beal Street
<br />Sb. COUNTY
<br />Hall
<br />1oa:MARITAL$TATUS AT TIPM OF DEATH R Married 0 Never Married
<br />Q Married, but sted Q Widowed 0 Divorced 0 Unknown
<br />111 FAT)IER`$ AME: (FIf 4 Middle,
<br />Eliseo ...:VelaSlxi Ramirez
<br />Le
<br />Suffix)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />(
<br />8d COUNTY OF DEATH
<br />Hall
<br />9a. APT. NO.
<br />91. ZIP CODE
<br />68801
<br />19b. NAME OF SPOUSE (First, . Middle, Last, Suffix) If wife, give maiden
<br />Lilia Coronado
<br />12 MOTlEttS.NAME (First, Middle, Maiden;
<br />Maria de Jesus Rodriguez Ra 'DOSE
<br />13 .EVER IN Ii S ARMED' FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link) NO
<br />14a. INFORMANT -NAME
<br />Lilia Coronado
<br />14b. RELATIONSHIP 1
<br />Spouse
<br />t8. METHOD OF DISPOSITION
<br />Burial evE10.01.ation
<br />d Crefttadort £I Ento : bment
<br />p Removal CI Other (Specify)
<br />18a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />led CEMETERY, CREMATORY OR OTHER L
<br />Grand Island City Cemetery
<br />17e._ FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State).;,
<br />Apfel Funeral Horne, 1123 W. 2nd, Grand Island, Nebraska
<br />ATION ..
<br />lab. LICENSE NO.
<br />1448
<br />CITY / TOWN
<br />Grand Island
<br />TM. DATE (I
<br />March 31.,
<br />CAUSE OF DEATH (See Instructions arid examples)
<br />18 PART IEnter the chain of event Fdlaeaaea, injuries, or compllcatenedhat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory artist, or ven#kuar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines B neeawy.
<br />.. faaaamlfiayp aeu*0. - .
<br />sequentially Set
<br />any, Nad)ng to
<br />eatuells
<br />DUE
<br />b)
<br />i, OR AS A CONSEQUENCE OF:
<br />EntertimUNDERLYING CAUSE
<br />(Bgaab or Injury that liNNated
<br />g in death)
<br />vita ren
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />iPICANT'CONOITWNS-Conditlona contributing to the death but not nOttestitga
<br />FEMALE:,:,
<br />..Notpregnantw thinpeaYear
<br />©;_Pregnant ti es of abatis
<br />Net pregnant, but fSa9a at within 42 days of death
<br />• NO pard. but pregnant 43 days tot yarbefore. death
<br />Q Unknown If regnant wSAin the hut
<br />year
<br />22a, DATEOF INJURY(Mo., Day, Yr.)
<br />M rch 23 2023
<br />22d. INJURY AT WORK?
<br />AYES .;CO NQ
<br />21a. MANNER OF DEATH
<br />Natural Q Hom)cids
<br />Accident ❑ ?ending Invatlpetlon
<br />® Suicide 0 Could not ba detNnninad •
<br />22b. TIME OF INJURY
<br />Unknown
<br />APPROXIMATE INTERVAL'''
<br />examittroeo
<br />i ons
<br />dead'
<br />e underlying cause given In PART I.
<br />21b..IF TRANSPORTATION INJURY
<br />© Ddvafloperaor
<br />'Q Paaeenger
<br />>0 PaAsarlan
<br />El MOT (Specify)
<br />•
<br />21c. WAS AN AUTOPSY Plaid
<br />in YES
<br />21d, WERE AUTOPSY PINOINDSAVA1
<br />TO COMPLETE CAUSE OF DEATk
<br />® YES Q NO.
<br />22c. PLACE C F INJURY -At home :farm *treat, factory, office building, construction efts etc.
<br />Home
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Gun shot wound to the chest causing subsequent arrest of cardiac function
<br />IldtC LOCA1t.)w'tot II4JON T s'MEETS i'IUND R, APT.
<br />110 East 6th Street: Apt. 2, Grand Island
<br />TE OP DEATH (Mo., Day, Yr.)
<br />23b. DATE SIGNED (Mo„ Day, Yr.)
<br />23c. TIME OF DEATH
<br />23d. Ti the bastof my knowledge, death occurred at the time, date and place
<br />• and due to the.cause() *toted (Signature and Title)
<br />28. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />28a, HAS ORGAN.OR TISSUE DONATION BEEN CONSIDERED?
<br />{YES to NO ]PROBABLY 0 UNKNOWN
<br />Nebra
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />March 30, 2023
<br />ka
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />March 24. 2023
<br />24b. TOF DEATH
<br />Unknown
<br />24d. fiME
<br />09:51
<br />Roe. On aha basis of examination endror Investigation, In My43310100 chapter Old
<br />he1hite date end place and due to the cause(*) *tgad. (Sign to and
<br />Kate Collins, Hall Deputy County Attorney
<br />®YES Q NO
<br />NAME,11TI. AND ADDRESS OFFCERTIFIER (Type or Print
<br />Kate Collins, Hall Deputy County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28b. WAS CONSENT
<br />Not Applicable M 24a 1s NI
<br />28b. DATE FILED BY REI
<br />April 3, 2023
<br />
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