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STATE OF NEBRASKA
<br />4t1109 walil a attyrfdtraa: tAOBy tttlwtY tio,nrgrytptt
<br />WHEN 7 115 COPY CARRIES THE RAISED SEAL OF STATE CF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />B A TAM COP YtF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA ;DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VIrALRECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />PATE Or ISSU�l1YOE
<br />vin/02
<br />LINCOLN, NEBRASKA
<br />202403400'
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGIST
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 DECEDENTS*AMtE '(8%f., Middle, Last, Suffix)
<br />Pedro Vazquez Moreno
<br />4. CITY A{1t7 STATE OR'TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />M.isXICD
<br />7. SOCIAL SEdliMitY NUMBER
<br />513 49-5484 ..
<br />AC;L1Ty AME (tf t rK tnstitution, give street and nu
<br />705 Redwood Rd
<br />:.,CITY OR TGYIIN OF DEATH (Include Zip Code)
<br />Grand island 88803
<br />2. SEX
<br />Male
<br />3. DATE OFDEAT..
<br />October 20.2
<br />5a. AGE • LastBirthday:15b. UNDER 1 YEAR
<br />(Yrs.)
<br />64
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />8. DATE
<br />January 27,
<br />HMar
<br />8a. PLACE OF DEATH
<br />HOSPITAL Q inpatient
<br />❑ EaOu patient
<br />[] DOA
<br />aesideNCE, STATE
<br />Nebraska
<br />TREETAND NUMBER
<br />765 RedIQod Rd
<br />OTHER ❑ Nursing Home/LTC `-
<br />Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />9b. COUNTY
<br />Hall
<br />cTITS AT TIME OF DEATH 0 Married 0 Never Married
<br />arried, but separated 0 Widowed ® Divorced ❑ Unknown
<br />1, FAME'S*, . (FIYst, Middle, Last, Suffix)
<br />Milan VBZQVGZ <.:
<br />U.S.ARMED FORCES/
<br />(Yes, No, or Unk.) No
<br />5. METHOD O.F. DISPOSITION
<br />�:.Burisl ❑t3sonalton
<br />: Cremation D Entombment
<br />O #tenw al ❑ Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />lulu CITY LIIEI't
<br />Yes C(;ro
<br />Ob NAME OF. SPOUSE (First, Middle, Last, Suffix) Ifwife, g
<br />Give dates of service If Yes.
<br />14e. INFORMANT-NAMI
<br />Heman Vazquez
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />16d. CEMETERY, CREMATORY OR (nem LOCATION
<br />mat
<br />12. MOTHERS NAME (First, Middle, Maiden
<br />JUana Moreno
<br />14
<br />Westlawn Memorial Park Cemetery
<br />FUNERAL HCME NAME AND MAILING ADDRESS (Street, City or Town, Stato
<br />`ivii gston ¢nderri ann Funeral Home, 601 N. Webb Roatk Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1439
<br />CITY / TOWN
<br />Grand Island
<br />iegwntiel
<br />toy isadir
<br />itit
<br />in
<br />18C DAT
<br />Ociobi
<br />CAUSE OF DEATH (SeeInstructions and examDlesl
<br />les,: injuries, or complicatonsdhet directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />dilation without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause one line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />cAkISLE;Fi bt :�y . a)
<br />dnaitignreauetng'
<br />Metastatic kidnoy cancer •
<br />DUE
<br />Ibt conditions, t b)
<br />to the (Muralists!!
<br />r, tw UNtf@RGYINa OAU
<br />Yea dr iryur that inklafigl
<br />n alai resulting in death)
<br />APPROX
<br />OR AS A CONSEQUENCE OF:
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />TO, OR AS A CONSEQUENCE OF:
<br />8.IYA*T fi OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death butnot ref
<br />rootdjabeWe,. coronary artery disease, hypertension
<br />. IF:FEMALE:.;'.
<br />:::Not pragnsat wtthih prat.geer
<br />A
<br />Ptrgnaut at ijme df ti etn:
<br />NM pregnnrl:; but pre9A5af t wkidn 42 days of death
<br />0 Not pregrent; but pregnant 43 days to 1 year before death
<br />❑.,Unknown 8 #uegnen* kdth.4n the post year . .
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident D Pehding Investigate/ft
<br />0 Suicide 0 Could not be determined
<br />22a •:DATE OF:IN4:
<br />•
<br />e, Day. Yr.I
<br />22b. TIME OF INJURY
<br />£)nOF IN4UR
<br />In the underlying cause given in PART I.
<br />21b,:IF TRANSPORTATION INJUR
<br />pDriver/Operator
<br />© Paassnger
<br />Pedestrian
<br />❑ Other (Specify)
<br />19. W
<br />OR CCttl lNtE1t!
<br />one,
<br />rSCAi.Exmi.
<br />21c. WAS AN
<br />0 YES
<br />21d. WERE ALM*
<br />TO COMPLETE
<br />C YES
<br />home, farm, street, factory, office building, constnrctldi
<br />22d. INJURY AT WORK?
<br />NO:
<br />Ivl;Sfitft
<br />22e. DESCRIBE HOW INJU
<br />Y OCCURRED
<br />T S NUMBER, APT.Nti.
<br />23a, DATE OFDEATH (Mo., Day, Yr.)
<br />October 20, 2022
<br />CO Yf$OWN','•
<br />STATE
<br />23b. DATE SIGNED (Mo, Day, Yr.) 23c. TIME OF DEATH
<br />October 2x,2022 12:11 PM
<br />Rad TO the ball er 4ty knowledge, death Occurred at the time, date and place
<br />ant ifustOth*au,e(s) stated (Signature end Title)
<br />Chad Vieth, MD
<br />5. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />in YES El NO ❑ PROBABLY f] UNKNOWN
<br />NAME,'RTI.I" AND ADDRESS OF CERTIFIER (Type or Print
<br />Chaif Viet, MD, 2116 W Faidley #400, Box 9802, Grand !stand, Nebraska, 68803
<br />RECt81#ARS'SiGNATURE , y
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TI
<br />24d. TIM
<br />4e. On the basis of examination and/or investigation, In My op
<br />the tens, date and place and due to the causes) sated (8
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ENO
<br />26b. WAS CONSENT OMAN
<br />Not Applicable If 26e Is
<br />Ye
<br />28b. bATE FILED BY I
<br />November 1, 2022'
<br />�r.
<br />
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