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STATE OF NEBRASKA <br />c,s•>•' s,.'%.4�'isSp0l'��j5i'•�'eo:'sfelPlrffi�l4)IJ�Sn�tr��'rrr�t!%i2t4.4�d.a�n>•.'-:a':4451'I'1'l�IY111J:gc': 'o•Z45ri9'11..60. ^..:. .2t4411�1:1:1'1,1PIdJg>•'.,»:`' MMf.af <br />1 : COP/' 1 RAISED SEAL OF STATE OF NEBRASKA, tT CERTIFIES THE DOCUMENT BELOW T <br />1E.G k ;: THE ORI WAIL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND — <br />`RV S OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />202504774 <br />*M&+ <br />SARAH BOHNENKAMP <br />ASSISTANT STATE REGIS R <br />DEPARTMENT OF HEALTH <br />AND HUMAN SERVICES <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />CERTIFICATE OF DEATH \ <br />Last, Suffix) <br />EIGN COUNTRY OF BIRTH <br />and number) <br />p Code) <br />sb.000NTY <br />Hall <br />® Married 0 Never Married <br />Wldowid 0 Divorced ❑ Unknown <br />€D PORCES9 r ibtp dates of service if Yes. <br />6a. AGE • Last Birthday <br />(Yrs.) <br />b. UNDER 1 YEAR <br />62 <br />t. PLACE.OF DEATH <br />HOSPITAL 0 NfpaUetit <br />❑ ER/Outpatient <br />❑ DOA <br />2. SEX <br />Female <br />6c. UNDER 1 DAY <br />HOURS <br />-OTHER 0 Nursing Horns/LTC <br />® Decedent's Home' f� <br />0 Other (Spec lfy) <br />8COUNTY OF DEATH <br />Hall <br />9f. ZIP CODE <br />68803 <br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give <br />Armando Torres Gutierrez <br />I12. MOTHER'S+NAME (First, Middle, Malden <br />litlargarita Lopez Valerie <br />14a. INFORMANT -NAME <br />Armando Torres Gutierrez <br />EMBALMER -SIGNATURE <br />Not Embalmed <br />.EMETERY, CREMATORY OR OTHER LOCATION <br />ntral Nebraska Cremation Services <br />Ni4ME`AND MAILING ADDRESS (Street, City or Town, State) <br />ila Hor e, 2929-$. Locust Street, Grand Island, Nebraska <br />CITY / TOWN <br />Gibbon <br />CAUSE OF DEATH (See instructions and examples) <br />11. AKT 1. adl4r;th. chats or Anyy, �Iiseasa., to un.a, or compllcat ons4hat directly caused the death. DO NOT enter tannins' *vents such as cardiac arrest, „ A. <br />; itotyt,iltte_at. rfihfiltUonvvfth s stowing the etiology. DO NOT ABBREVIATE. Enter only one cacao on a line. Add additional lines if necessary. <br />tMMEDUITE CAUSE: ciei <br />i ED1 TB seal Or <br />(atu <br />AS A CONSEQUENCE OF: <br />AS A CONSEQUENCE OF: <br />R AS A CONSEQUENCE OF: <br />-Conditions contributing to the death but not reaufting to the underlying cause given in PART I. <br />vellhet4 days of death <br />4$ (1►y41G' lY before death <br />21a. MANNER OF DEATH <br />® Natural \❑ Homicide <br />❑ Accident ❑ Pending hwestigetion <br />❑ Suicide ❑ Could not be determined <br />22b. TIME OF INJURY <br />I b. IF TRANSPORTATION INJURY <br />0 Dnver/Operator <br />0 Passenger <br />❑ Pedestrian <br />❑ Other (Specify) <br />21c. WAS <br />21d. WERE A <br />TO COMI <br />0 YES <br />22c. PLACE OF INJURY-Athonts, farm, street, factory, office building, constni <br />BE HOW INJURY OCCURRED <br />T;fRNUMBER,APT.NO. CITY/TOWN STATE <br />23c. TIME OF DEATH <br />:4 P <br />r" $ car eed at the time, date and place <br />mature and Tide) <br />TO THE DEATH? <br />❑ UNKNOWN <br />ER (Type or Print <br />416 N °Diets Ave, Grand Island, Nebraska, 68803 <br />0./11—/L.Ee/?.4'mp <br />I <br />24a. DATE SIGNED (Mo., Day, Yr.) <br />24C. PRONOUNCED DEAD (Mo., Day, Yr.) <br />24d TIME P <br />24e, On the basis of exeminadon and/or Inwntlgetlon, In my opkti <br />the lime, dots and place and due to the causal') eta ld. (al <br />26a. HAS ORGAN OR Tt$SUE DONATION BEEN CONSIDERED? <br />❑ YES ®NO <br />26b. WAS CONSE <br />Not Applicable <br />28b. DATE FILED <br />May 9, 2025 <br />