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<br />STATE OF NEBRASKA
<br />8tiri4yt..S.?,:..; r4trilISTfflifl5° ;.,:r set
<br />W 1i N THIS;.: "COPY CARRIES THE RAISED:: SEAL. OF:.:THE; STATE OF NEBRASKA, IT
<br />;:;CER7 FIES';'.THE - -DOCUMENT BELOW TO BE . A TRUE COPY;' :OF THE ORIGINAL .RE
<br />ON FiLE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />•RECORDS:OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR,VITAL RECORDS
<br />Di TE OF?ISSUANCE •:..: : •
<br />5/1420•0 202502658 3M
<br />LINC(TLN, NEBRASKA SARAH BQHNENKAMP ,
<br />n. ASSISTANT STATE REGISTRAR
<br />2 0 2
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />i.OSOEDENTS-NAME;:(rst, Middle, Last, Suffix)
<br />Reynaldo''. ':Ramirez
<br />4. CITY AND STATE OR;TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Mexico
<br />7.:SOCIAL SECURITY UMBER
<br />608 .-6164....:
<br />64: FACILITY-NAME.(If not lnetttutlun, give street end number)
<br />CHI Health St. Francis
<br />6c. ItTY0ft TISVN:OF'OEATH (Include Zip Code)
<br />'Grand"Isla11d<:.68603
<br />9a. RESIDENCE SPATE
<br />Nebraska
<br />ed, $T1tEET AND NUMBER
<br />814.5'<t`Pterry::,Srte�et: '
<br />Ob. COUNTY
<br />Hall
<br />10ii iTAr STATIO At TIME OF DEATH ® Married 0 Never Married
<br />0 Monied, but separated ()Widowed 0 Divorced ❑ Unknown
<br />41.;FATHER'S. M (F1f'pt, Middle, Last, Suffix)
<br />I rldatetio RR.arnirez
<br />13;EVER'IN U$ ARMED FORCES? Give dates of servke If Yes.
<br />(Yes, No, or Unk.) NO
<br />15. METHOD OF DISPOSITION
<br />• >Tlurial [ :pant tlon
<br />Cremations C .Entombment
<br />Q Removes:"s Qofiier (Specify)
<br />64, AGE • Last :Bfrthd i
<br />(Yrs.)
<br />61.
<br />Sti.:LINDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Si.: PLACE 0I`:'DEATli
<br />HOSPITAL:::'�$] 'inpatient
<br />E RiOutpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />OTH
<br />MINS.
<br />ad. COUNTY OF DEATH
<br />Hall
<br />Pa. APT. NO.
<br />lob. NAME OF SPOUSE (First, Middle, Last,
<br />Blanca Castaneda
<br />14a. INFORMANT -NAME
<br />Blanca Castaneda
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />Si. ZIP CODE.
<br />68801
<br />12::;MOTHER'S-NAME (First, Middle, M
<br />Jose l a:` Ramirez
<br />lob. LICENSE NO.
<br />led. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />17e,FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State)
<br />All Folth Funer'al;Home. 2929 S. Locust Street, Grand Island: Ne
<br />CAUSE OF DEATH
<br />0 ins#ruotiD a: and examples)
<br />is. PART i. Enter the chain of events- dIsases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without shoring the etiology. DO NOT ABBREVIATE Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />1airii;cAusEir''::: a}Acute HypoXIC Respiratory Failure:::;.:;
<br />tintease::E,r:eonttitian:resu ldiip:;'
<br />I a i„i
<br />Sequentially list conditions, If
<br />any, bidding to tin cause listed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Respiratory Distress Syndrome
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />004rthkuNtiti61400AU5L c}CCVID-19 Viral Pneumonia Confirm::;
<br />tdlasitie or hhli#y.that:ititti.bd
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST' d)
<br />11L.PARTS. OT'HER:: SIGNI::FICANTCONDMONS•COndltlons contributing to the death
<br />2O. itnFEMALE:..
<br />_..::.:.:::'... grantaatett peat year
<br />Prsgnsnt t:tlmso,daitiy
<br />. sett ptentwer, biit: pi giiant within 43 days erf death
<br />Q Not (Regnant, Ind pregnant 43 days to tel year before death
<br />90knovm)[,pre9n n wkNn tM peat ysar
<br />22 DATE OF:10.110R E (Mti„ Day, Yr.)
<br />22d. INJURY AT WORK?
<br />DYES ...ONO,.
<br />OCA:DD i:OF; INJURY • STREET & NUMBER, APT.NO.
<br />DATE OF DEATN (Mc., Day, Yr.)
<br />April 28, 2020
<br />b
<br />MI
<br />d:'to11
<br />IGNED (Mo., Oly, Yr.)
<br />E, Q20
<br />nut
<br />21a. MANNER QF DEATH
<br />Natural Hotnitids .. >
<br />Q Accident ID: Pending Irtyestigation?
<br />Q Suicide Q Ceuld not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF.:I
<br />22* DESCRIBE HOW INJURY OCCURRED
<br />C!DffTOWN
<br />230. TIME OF DEATH
<br />02:08 PM
<br />Only Idlaiiledge, death occurtSd at the time, data and place
<br />Pausge) stated. (signature and Title) ..
<br />Shoaib Z. Juneio, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />Q'YES :':]<Nci's''Q PROBABLY 0 UNKNOWN
<br />2T. NAME, TITLE AND ADRESS OF CERTIFIER (Type or Print
<br />Sfattaib`Z. June*, MD, 2620 W Faidley Aye, Grand Island, Nebraska, 68803
<br />26a. REGISTRAR'S SIGNATURE
<br />c/3'asE'ac en.r
<br />6. DA;
<br />underlying cause given In PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />:.. f#:irarlOperstor . .
<br />Q. Passenger
<br />0 Pedestrian
<br />Q Other (Specify)
<br />2
<br />t�FF 0EAlf tlaL
<br />28, 2 0 :.. ,'s€
<br />E�IRT}f€(A
<br />xY
<br />o.; IAy Yr)
<br />Mn5
<br />NO'
<br />n Rat
<br />6c: DATE (MO., Day,
<br />May 4. ,Zti4+2?;<r`
<br />APPROXIMATE INTERVAL
<br />WAS AN.AIITOPSY
<br />WERE AUTOPSY F NDINGS OA/LADL;E
<br />TO COMPLETE CAUSE OF'0EA74HR
<br />QYE
<br />URY.Affiaine, fartn,.etreet, factory, office bufding, e
<br />STATE
<br />140 1 E SIGNED (Mc., DC;•, Yr.;
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />74r mid till hash of examination andior 1
<br />: the tin., date and place and due to the
<br />26e. HAS ORGAN:QR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES;' :: ::::::: i7 NO
<br />24d. TIME PRONOUNCED DEAD
<br />tab. WAS CONSENT ORAiY,TE
<br />Not Appllcsbls N 26e Is
<br />28b. DATE FILED BY RI
<br />May 11, 2020
<br />
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