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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA mug 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 OF ISSUANCE
<br />9/28/2023
<br />LINCOLN,NEBRASKA
<br />SARAH BOHNENKAMP'
<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 />1 pact DENTSNAME (First, Middle, Last, Suffix)
<br />Enrique AMarez: Tejeda Sr
<br />4. CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Mfextco
<br />i SOCIAL. SECURITY'NUMBER
<br />Sot03 2070
<br />8b.'- FACILITY -NAM Etfi'notIn+tnutlo' Peva event arte, a.,r^aopr)
<br />Bran Medical Center West
<br />8c crrY OR TOWN OF DEATH (Include Zip Code)
<br />UnColn 64502
<br />9a. RESIDENCE STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />2311648
<br />3. DATE OF DEATH (Mo.,;-DAyr 146)
<br />Augu t 23;4023
<br />8. DATE CIF BIRT ..• M O.,
<br />8a. PLACE OF DEATH
<br />HOSPITAL ®Inpateft4
<br />® ERIOu patient
<br />D DOA.
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Horne
<br />❑ Other (Specify)
<br />18d. COUNTY OF DEATH
<br />Lancaster
<br />9d .STREET AND NUMBEI>>
<br />404E 1 Sth: Street
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married E] Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (Phut, Middle,
<br />Santiasto Alvarez
<br />13: EVER IN U S ARMED FORCES
<br />(Yes, No, or Unk.) No
<br />18. METHOD OF DISPOSITION
<br />['Burial ❑Dona(lon
<br />Crernation J Entombment
<br />❑'Remgvai 1I Oth®rOpacity)
<br />9c. CITY OR TOWN
<br />Grand: Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />lab NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name;'
<br />? Give dates of service If Yes.
<br />12. MOTHER&NAME (First, Middle, Maiden' Surname
<br />Juana Tejeda Meiias
<br />14a. INFORMANT -NAME
<br />Enrique Alvarez Jr
<br />16a. EMBALMER -SIGNATURE
<br />Laurie D. Sheffield
<br />16b. LICENSE NO.
<br />1397'
<br />18c. DATE (Mo., Day, Yr:)
<br />August 200t02$ '<
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />74;. FUNERAHOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Ail Faiths ltnelai Dome. 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH' Mee:tnstructicros and examples)
<br />Fb, ZIp Code
<br />Is. PART I, Enter the otuiln of events- -0lafaaa, Injuria, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respirator, arrest, or vendkular fibrillation without Snowing the etiology. DO NOT ABBREVIATE. Enter only one cause on a tine. Add additional lines a necessary.
<br />IMMEDIATE CAUSE:
<br />a) CENTRAL NERVOUS system Nocardiosis
<br />atm EDIATE CAUSE IFkuI ..,
<br />Usenet or 4a idition t.*U*t NF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentlsly list conditions, k b)
<br />arry,'leading to the, esus gated
<br />,8 ontihea
<br />Eats 1ne UNOERL,YdtO CAUSE
<br />'+ id+seauM(hjuryshatlitntaepN
<br />tit events resulting In dant)
<br />FAST
<br />DUE TO, OR A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />ANT CONDITIONS -Conditions contributing to the death but not
<br />suiting to tits underlying cause given in PART I.
<br />IF'FEMALE.
<br />Not paepat9 wkhin pest Ytat
<br />1: aregnadt saline of deatA ;>
<br />t-� 71ef.pre9nant but pregnant vdttt 42 days of death
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />tkn?vm I RCegnant wit in the pat year
<br />2a ":DATE OF (N,IURY (Mo Day, Yr.)
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />0 Suicide 0 Could not be deteniilned
<br />22b. TIME OF INJURY
<br />22c. PLA;I
<br />UR'FAt hi
<br />21b. IF:TRANSPORTATION INJURY
<br />© Dnver/Oparator
<br />Passenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />19. WAIS MEDICAL'EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YEs) NG
<br />21c. WAS AN AUTI,S Y?I
<br />21d. WERE AUTOPSVFleil
<br />TO COMPLETE CAUSI
<br />❑ YES ❑ NO ..
<br />, farm, street, factory, office building, construction site
<br />AVAN.ABLE
<br />OF DEATH?
<br />INJURY AT WORK?
<br />©YES No
<br />SCRIBE HOW INJURY OCCURRED
<br />DAMN' Of'WRAY . STREET & NUMBER, APT.NO. CITY/T
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 23, 2023
<br />23b DATE SIGNED (Mo., Day, Yr.)
<br />August 24 :2023
<br />•
<br />STATE
<br />23c. TIME OF DEATH
<br />07:28 AM
<br />Tu the best of my knowledge, death occurred at the time, date and place
<br />acid des br the cause(s) stated. (Signature and Title)
<br />Mitchell D Hervert, DO
<br />010 TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑YES NO PROBABLY 0 UNKNOWN
<br />27 :0AME,TITI. ANi'r AESS OF CERTIFIER (Type or Print
<br />i iltr le11
<br />O:Hervek DO, 2300 S 16th St, Lincoln Nebraska, 68502
<br />z
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />i r . 24e. Qe the Wsia of examination endfor Investigation, In my opinion de.tH odcurredat
<br />ek thetime, date and place and due to the cause(a) stated. (Signature artd Tito)
<br />eS
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />26a. HAS ORGAN OR TISSU.E.DONATION :BEEN CONSIDERED?
<br />❑ YES I5D NO
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO 43 YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 29, 2023
<br />9/28/2023 item 12, "Maria Luisa Jaquez" To "Juana Tejeda Mejias"
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