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<br />At
<br />STATE OF NEBRASKA
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<br />lili11116,§�t @I)�%iilrek�I�O;4,,,`
<br />EN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />IE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />UMAIII SERVICES, ViTAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />LINCOLN, NEBRASKA
<br />202403728
<br />SARAH BOHNENKAi R
<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, DECEDEN I S}NAME..Ftrst, Middle, Last, Suffix)
<br />lwmanuit#1 Met'cedes Solis Jr
<br />4. CInt AND 'STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Los Angeles, California
<br />7- SOCIAL SECURITY NUMBER
<br />554-06-4896 . .
<br />58.:AGE - Lasf`Birthday`
<br />(Yrs.)
<br />eB
<br />8
<br />8b FAOILITY±NAME (1f not Institution, give street and number)
<br />Premier Estates
<br />nesaw
<br />Sc.:OiTY QR TOWN OF DEATH (include Zip Code)
<br />kenesaW 1;8966
<br />ea RESIDENCE
<br />Nebraska
<br />TATE
<br />8d $TREET'AND NUMBER
<br />1!05 I,.IIfi1r Street
<br />9b. COUNTY
<br />Hall
<br />6
<br />NDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH :
<br />NQ$PtTA1. ❑ InpaNsht
<br />"❑ ER/Outpatient
<br />0 DOA
<br />105 MARITAt:STATU5 AT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated ❑'Widowed 0 Divorced 0 Unknown
<br />11.FATHER'S-NAME (First, Middle, Last, Suffix)
<br />Emanuel Mercedes Solis Sr
<br />ER IN U.S.ARMED FORCES? Give dates of service if Yes,
<br />to No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />0 13urlat [Dorton
<br />Cremation ❑ Entornfbrnent
<br />U Removal 0Other (Specify)'
<br />NAMEMiddle, Last, Suffix) If wife, gi
<br />9c. CITY OR TOWN
<br />Wood River
<br />HOURS
<br />MINS.
<br />9 DATE OF DEATH o, #Niy Yt )'
<br />December_ 9, 2023
<br />OTHER ® Nursing Horne/LTC
<br />❑ Decedent's
<br />❑ Other IS
<br />I8d. COUNTY OF DEATH
<br />Adams
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />Suzanne Garriques
<br />14a. IN FORMANTVNAME
<br />Suzanne Solis
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S•$AME (First,
<br />Evelvn... Wichman
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a FUNERAL;HOME NAME AND MAILING ADDRESS (Street, City or Town, State):,.
<br />Abfet Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />9$.INSIDEden LIMITS:
<br />® r ❑ °hD !,
<br />Middle, Maiden Si
<br />CITY / TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See Instructions and examples)
<br />116 RE&A11QN41441P
<br />SDOUSe
<br />D
<br />.
<br />16e0. ATE (Ma., Day, Yr t.
<br />DATE ben 2'i,=2023
<br />1tb Z)i.
<br />6881)
<br />ft. PARTI. Enter thachain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enterterminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular faMllationwithout showing the etiology. DO NOT ABBREVIATE. Enter only one cause one live. Add addhMnel lines If necessary.
<br />IMMEDIATE CAUSE:
<br />WSW E (Rig a)Respiratory Failure
<br />Maltase orcon lifon resenting
<br />k deaths
<br />Sequentially list conditions,:If
<br />any, Isadina tothe cause listed
<br />Ent" tn. UNt}F...
<br />(disease er 'flutyl
<br />the events result
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Lung Cancer
<br />DUE TO, OP AS A CONSEQUENCE OF:
<br />c)
<br />d
<br />In deal
<br />DUE. TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18. PART it OTHER MONORCANT CONDITIONS -Conditions contributing to the death but n
<br />Hospice Cars
<br />E20. IF FEMALE:
<br />❑ Notpregnirltwiadnpeat`ye
<br />0 PregiSM satins of oeat:.:,.
<br />❑. Net pregn*m. but pre_n fit within 42 days o' death
<br />0 Nat pregnant, but pregnant 43 days to:I yes before death
<br />0 Unknown ifpregnam whhkn ars past year
<br />22a. DATE OF;INJURY (M+tr , Day, Yr )
<br />22d. ATWORK?
<br />YES O NO
<br />21a. MANNERODEATH
<br />® Natural 0F Hod kfde
<br />❑ Accident ❑Pending InuestigatY.on
<br />El Suicide ❑ Could not be determined
<br />resulting; In the underlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />Drlvlr/Operator
<br />❑ P4asenger
<br />❑ pedestrian
<br />❑ Other (Specify)
<br />19. WASMEDILi.LEXAIA)M I
<br />OR CORONEi4 Ct fAC$ED? ;,
<br />©YES
<br />21c. WAS AN AUTOPt)`I
<br />in YEs IgINQ
<br />21d WERE AUTOPSYNOINQS Aw/tiLgBtiL
<br />TO COMPLETE CAUSE Ofd DEATH?'
<br />❑ YEs Q NO
<br />22c. PLACE OF INJURY -At home. faun; street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ICAT= >OF INJURY. 3
<br />NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />December 19, 2023
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr 23c. TIME OF DEATH
<br />Dupcel : ber:20. 2023 12:50 PM
<br />29.: Totiw bean of my knowledge, death occurred et the time, date and place
<br />and. due to tt . tauseIa) stated. (Signature and Title)
<br />Michael A. Donner, MD
<br />26. DID TOBACCO USE.CONTRIBUTE TO 171E DEATH?
<br />0 YES fl NO al PROBABLY 0 UNKNOWN
<br />41.NAME,17114.. ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue, Grand island, Nebraska, 68803
<br />STATE
<br />ZIPfr`ODE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME
<br />DEATH
<br />24d. T(ME PR t..DEAD,
<br />24.0n the.hesis of examination and/or investigation, in my
<br />th►tlpte, date end place and due to the cause(alaatsa.
<br />28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES IENO
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENTGRAN7
<br />Not Applicable if 28a is NO
<br />Ni
<br />28b. DATE FILED BY REGIS'VRAI
<br />December 26, 2023
<br />y, Yr.)
<br />
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