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<br />WHEIII THIS <? COPY CARRIES THE RAISED': • SEAL OF 'THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY :OF THE ORIGINAL RECORD
<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 />DATE OF:ISSUANCE
<br />7/20/2020
<br />LINCOLN, NEBRASKA
<br />2.1.14
<br />vr4.�d ".7 a Iktt,r
<br />SARAH BOHNENKAMP
<br />(rF 9ASSISTANT DEPARTMENT OF EATH REGISTRARSTATE
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. p CENTS NAME: (First, Middle, Last, Suffix)
<br />Rachel G Mendez
<br />4. CITYAND STATE ORTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7, S*CtA :SEGURl7
<br />507 34-59 1:
<br />CBER
<br />fib. FACtLITYNAME(If fl©t Institution, give street and number)
<br />CH.I. Health Good Samaritan
<br />Be,:.'GITY'OR TD7NiN:{?F.:. DEATH (Include Zip Code)
<br />Kearney 88848 '''
<br />Sa. RESIDENCE -STATE
<br />Nebraska
<br />Hd.>STREE.T AND NUMBER.
<br />4205 6th Avenue >:
<br />Ob. COUNTY
<br />Buffalo
<br />10a MARITAL:.STATUS•AT TIME Of DEATH ® Married 0 Never Married
<br />❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 F4THERSiAME (First, Middle, Last, Suffix)
<br />Prank Guerrero ;'
<br />13.'EVER <IN LLB: ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />5a AGE-LAOtBirHtdew:
<br />(Yrs.)
<br />87 ..
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />84. PLACE OF. DEATH
<br />HOSPITAL ®'Inpatient
<br />0 ER/Ou patient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Kearney
<br />HOURS
<br />MINS.
<br />Uh; S
<br />20 09153
<br />3. DATE OF DEATH. (M4„Day .'Ft )
<br />July 12, 2020.:.
<br />6. DATE OF BIRTH (Mo.,
<br />August 17:-.::1932.,
<br />OTHER ❑ Nursing Home/LTC
<br />0 Decedent's Home
<br />❑ Other (Specify)
<br />led. COUNTY OF DEATH
<br />Buffalo
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68845
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give mai
<br />Vincent Mendez
<br />14a. INFORMANT -NAME
<br />Olivia Molina
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Ernestine Cantu
<br />y :Fri)
<br />9g 1NSN3E CITY.tIMITs.
<br />® YES ❑ sole
<br />e
<br />14b. RELATIONSHIP
<br />Daughter
<br />ECED
<br />15. METHOD QF DISPOSITION
<br />Budel ; [, Donation
<br />Cremation: ❑ EntorYlbment
<br />Removat ❑Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />16b. LICENSE NO.
<br />1448
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Cemetery Grand Island
<br />h a.FVNERAL;HOME;NAME AND MAILING ADDRESS (Street, City or Town, State).
<br />Apfel Funeral tint e, 1123 W. 2nd, Grand Island, Nebraska:::
<br />CAUSE OF DEATH (See instructions and examples)
<br />14. PART I. Enter thechaln of events- diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />ISIBEDtATt ..E mine) a) Klebsiella Bacteremia
<br />dihSdse grcon±iit:on rasuiting.3
<br />In deal*:'"
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditioned? b►Aspiration Pneumonia
<br />. any, leaping to thecausa listed
<br />the events tea ultIna in d
<br />LAST
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />USE c)Ceretsrovascular Infarct
<br />I DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 ::PART II OTHER SIGN FECANT CONDITIONS -Conditions contributing to the death but not resuttfng in the Underlying cause given in PART I.
<br />16c. DATE (ttlo„ Day, Yr) ...:.;,.
<br />July 17, 2020
<br />Nebraska
<br />.:1Tb, 2)p,Code::
<br />68801.
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Days ::..
<br />onset t
<br />Days
<br />ansettti Beath
<br />onset to death
<br />19. WAS MEDICAL'EXAMINER:
<br />OR CORONE_R:CONTAO'FED?
<br />❑ YES I No
<br />20, IF:FEMALE;...
<br />Notpfapnentawtdttn pail year
<br />Pregnant at ltma of death
<br />❑r Ndt ptegnalttr butpnipmam within 42 days of death
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />0 .Unknown If.pregna . within the pant year
<br />224i DATE OFINJURY (Mo., Day, Yr.).
<br />22d. INJURY AT WORK?
<br />0 YES.::. NO
<br />22f LOCA
<br />2�1a1. MANNER OF DEATH
<br />iiEl Natural 0 Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />:❑ Driver/Operator
<br />.::❑ Passenger
<br />El. Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFOR
<br />❑ YES ®NO
<br />:D
<br />21d. WERE AUTOPSY FINDINGS AVAAILABL E-
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES ©NO
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />ON OF INJURY:;- STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />July 12 2020
<br />23b DATE SIGNED (Mo., Day, Yr.)
<br />u)v 122020
<br />CITY/TOWN .. .
<br />23c. TIME OF DEATH
<br />10:30 AM
<br />egg
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH"
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />tad T+ tie: (aria[ ofi My: knowledge, death occurred at the time, date and place
<br />and due to tbe:cause(s) stated. (Signature and Title)
<br />Alexander Kaclanas, MD
<br />'44e.:On ttie:hesis of examination andlor investigation, in my opinion deiitl!
<br />::the tuna, date and place and due to the causes) stated. (Signatureey
<br />25. DID.TOBAC,r.O USE;CONTRIBUTE TO THE DEATH?
<br />YES a NO ❑ PROBABLY 0 UNKNOWN
<br />2 1.:(AMkti*BAND ADDRESS OF CERTIFIER (Type or Print
<br />AIexanderKaganas, MD, 10 E 31st St., PO Box 1990, Kearney, Nebraska,.:68847.
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />El YES ( NO
<br />26b. WAS CONSENTGRI
<br />Not Applicable If 26a Is NO
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,)
<br />July 15, 2020
<br />Nory idittltnp
<br />E4I,hA11Fb3J..•:
<br />
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