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STATE OF NEBRASKA
<br />NAA¢cex 'ti6tlir�iSAa.?.c...r. Wi'!Rtte ' tYl//�,♦ r(lIl➢�'�3�....... ''i!l54lDdMiNt+g A:
<br />WHEN 3`HIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE 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 o(+ fSs:i c.
<br />3/91;2023"
<br />LINCOLN, NEBRASKA
<br />202400544
<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 />II1 DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />• Manuei Vega
<br />4 CITY`AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />San Marcos, Texas
<br />SOCIAL SECURITY NUMBER
<br />507 70442
<br />Sb. PAC:tiTY-NAME'(If"Sot Institution, give street and nt,mbor)
<br />olumbus<Comm,unity Hospital
<br />CITY: Ce TCI AIN OF DEATH (include Zip Code)
<br />Columbus :8x 82:;..
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />so. :STREET ANDNUM R
<br />324 Lake Street
<br />9b. COUNTY
<br />Hall
<br />1/I: #IARITAL:STATUS•AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />1 Fh7N.E.BI NAIVE (First, Middle, Last, Suffix)
<br />:Henrik
<br />1/eila
<br />13. EVSR ea II,t1i AR111ED>FORCE$? Give dates of service If Yes.
<br />(Yes, No, or Unice Yes 01/28/ 972-01/27/1975
<br />16 METhOD OF DISPOSITION •
<br />o Burial ❑ Donation
<br />Crematiuni Q Entombment
<br />❑'Removat ❑•Other.(Specify)
<br />Bas AGE - La
<br />(Yrs.)
<br />70
<br />Birthday
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL #npatipnt
<br />r� ER;Oufpatient
<br />❑ 4p4.
<br />9c. CITY OR TOWN
<br />Grand: Island
<br />HOURS
<br />MINS.
<br />3. DATE OP DEAa1NIO., D1#yr y*..;
<br />February 25,;2023:
<br />6. DATE OF BIRTH -(Mo.,
<br />July 27,-.1952
<br />OTHER 0 Nursing HomeILTC
<br />0 Decedent's Hors
<br />❑ Other(SPecIy)
<br />1 6d. COUNTY OF DEATH
<br />Platte
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />Y
<br />lob. NAME OF SPOUSE (First; Middle, Last, Suffix) If wife, give maiden natio.
<br />Cathern Bacellia Vega
<br />312 MOTHER'S -NAME (First, Middle, Maiden Surname
<br />Juanita f odriouez
<br />14a. INFORMANT -NAME
<br />Cathern Bacellia Vega
<br />16a. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />1Sb. LICENSE NO.
<br />1495
<br />14b RElATIONSHi P.
<br />SPOUSE
<br />180. DATE (Me., Poi Yr.)
<br />March'2, 2023
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />a . INERAL:HOME NAME AND MA LING ADDRESS (Street, City or Town, ;State)
<br />AU Fadhs, `uneratHome, 2929 S. Locust Street, Grand Island,, Nebraska
<br />CITY ! TOWN
<br />Gibbon
<br />CAUSE OF DEATH (SO�Instruc one... and examples)
<br />PART I. Enter the chain of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respxatoty arrest, or ventrIcular fanTation,without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines If necessary.
<br />IdtMEDIATECAUSE0* ; a) Dehydration
<br />diswe or aondiffaa raauttksg
<br />in Nstil)> - DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, w b) Anorexia
<br />any,lga!gnp to the.:ORM listed
<br />en HMI.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Qjr c)End Stage dementia
<br />:or injwytlist NYafMted
<br />resulting in death)
<br />18.,PART IL:OTHER
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />'l Nat txle wsevlp Peat:f*r
<br />::iresQnard at time of tlsadt. �`
<br />#ldt Psi ve ,.Md Pts9nent withIn 42 days of death
<br />reOneM 40 days to year peen death
<br />❑ Not Pregnant; but p
<br />unknown I:plrgnrd r?pW Mie oast PO
<br />(SATE OP INJURY
<br />T CONDITIONS -Conditions contributing to the death but n
<br />. INJURY AT WORK?
<br />•
<br />OYES ❑NO::::..
<br />40C10IOMFOF IN:10
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Inyeatigatlon
<br />0 Suicide 0 Could not he determined
<br />22b. TIME OF INJURY
<br />22c. P
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />;STREET & NUMBER, APT.NO.
<br />23a. RATE OF'DEATH (Mo., Day, Yr.)
<br />February 25, 2023
<br />21b. IF _TRANSPORTATION
<br />❑ Ddver/Operator
<br />Pal anger
<br />❑ Pedestrian
<br />o Other (Specify)
<br />INJURY
<br />TA
<br />Nebraska
<br />vb. Zip Code,
<br />'88801
<br />APPIIpXIMATE DIT!RVAL
<br />onaet:ttl a.
<br />2 Days•
<br />:..
<br />l 6 ye
<br />onset to death
<br />19.'WAS ~MtritS :EXA
<br />OR CORONER'CONTACTED'
<br />❑ YES . O) NO21c. WAS AN AUTOPSY PERFORMED®ell?
<br />!.
<br />❑YES
<br />tsuiting in the underlying cause given In PART I.
<br />21d. WERE AUTOPSYF <NISNGS AYAE ABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />DYES 0 N
<br />CE OF INJURY -At hoofs, ;farm, street, factory, office building, construction
<br />CITYflT)WN::
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />February 28. 2023 02:25 AM
<br />24d ]Te:lhe Mist drmx tnowIedge, death occurred at the time, date and piece
<br />and due fe tRif uaeta) stated, (Signature and Title)
<br />Mark Howerter, MD
<br />26.010:TOBACCO USECONTRIBUTE TO THE DEATH?
<br />Q YES. NO ❑::PROBABLY 0 UNKNOWN
<br />NAME,11T4EANDAOQREB'i OF CERTIFIER (Type or Print
<br />Nark H6Wetter, l (0, 4600 38th Street, Columbus, Nebraska, 686
<br />26a. HAS ORGAN ORSSUE DO
<br />❑ YES e
<br />26a. REGISTRAR'S SIGNATURE
<br />STATE P`L+ODE:
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME
<br />DEATH
<br />24d. TIME PRONOUNCED DEAD..
<br />24e On the besis of examination and/or Investigation, 111 my opinion death O fled at
<br />(he Skne oats end place and due to the cause(s) stated. (Signature diel TSM)
<br />ATION•SE
<br />N CONSIDERED?
<br />26b. WAS CONSENT 'GRANTED?
<br />Not Applicable If 26a is NO ❑ YEa
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />March 3, 2023
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