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<br />COPY CARRIES THE RAiSEl:7:: SEAL. OF ::':THE. ;"STATE OF NEBRASKA, IT
<br />:GERTir IES ::>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 />RECORDSOFFICE, WHICH IS THE LEGAL DEPOSITORY O :. V TAL:RECORDS
<br />202600336
<br />DATE OF ISSUANCE
<br />5/14/2020
<br />• LINCOLN, NEBRASKA SARAH BOHNENKAMP
<br />202502650 .,14,04
<br />20230.421 : ADEPARTMENT OF HEALTH
<br />ISTANT STATE R
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />i.0E 0ENDS.NAmw:(Find, Middle, Last, Suffix)
<br />eYi1811 t}:. <:R.an1 tez
<br />4.OITYAND STATE #7RTERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Mexico
<br />7. 60otAI SE OURITY°Nl3INBER
<br />5&:AGE • Last Birthday
<br />(Yrs.)
<br />b:'FAAC€UTY='NAME`(if.rtot Institution, give et»et and number)
<br />CHI Health St. Francis
<br />8a crtir 6R TCWHN::OI='DEATH (include Zip Code)
<br />rand`Isla ricl ; 68803
<br />9a. RESIDENCE•STATE
<br />Nebraska
<br />9d,,;STREET ANSI NU.M!E1
<br />8:1 4 :S:I✓13err11::Steet
<br />9b. COUNTY
<br />Hall
<br />=IOOy ARITA# STA1U$:AT TIME OF DEATH ® Married ❑ Never MaMed
<br />❑ Married, but separated { Widowed ❑ Divorced ❑ Unknown
<br />11.FATHER'S•NAME .(First, Middle, Last, Suffix)
<br />Iridaltcil� `,' Ramirez
<br />61
<br />Sb; UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />r1s: PLACE OFDEATH::
<br />HOSPITAL IJ Inpatient
<br />❑ ER/Jutpatient
<br />❑ DOA
<br />CiTY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF 1
<br />April 28,
<br />6. DATE' OF wit -
<br />October
<br />OTHER [] Nursing Home/LTC
<br />❑ Decedent's Notts
<br />❑ Other (Specify)'
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />lie. APT. NO.
<br />f f. ZIP CODE
<br />68801
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If
<br />Blanca Castaneda
<br />as nd'Pk...,
<br />12:: MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Josefina Ramirez
<br />20 06004
<br />a.
<br />De Di 3JM111
<br />s< CNO<;!
<br />1 s ::t~yEl :#N /tiled ARMED FORCES? Give dates of service H Yes.
<br />(Yes, No, or Unk) No
<br />15. METHOD OF DISPOSITION
<br />�1t Btiiial Q'oonation
<br />it] Cremation OEntriffitiMint
<br />Q RBlttovefl' [ Other (Spealfy)
<br />14a. INFORMANT -NAME
<br />Blanca Castaneda
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1613, LICENSE NO.
<br />16d. CEMETERY; CREMATORY OR OTHER LOCATioN <' CITY I TOWN
<br />Grand island City Cemetery Grand Island
<br />17a. FUNERALHOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All'i~s'iths Funeral Home, 2929 S. Locust Street, Grand Island Nebraska
<br />CAUSE OF DEATH (See inetructioand examples)
<br />111. PART I. Enter the chain of events- dksaas, Injuries, or compileatlonsthat directly caused the death. DO NOT snits lamina; events such as taunt's arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enar only one cause on a lino. Add additional lines a nacassary.
<br />1MMEC ATE CAUSE:
<br />tlitATEcAui$E(Finei;';; a)Acute Hypoxic Respiratory Failure::,
<br />i ia..,.:ur condition resulting :.
<br />Sequentially list condtdone, it
<br />any, !lidding to the cantle
<br />Miter tiie:uNtIEItL' 1Na C* SE
<br />(diswi pi or Injd y:thatMttiited
<br />the events resulting In death)
<br />LAST
<br />1t FAR? II OTNEft`$
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Respiratory Distress Syndrome
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)COVID-19 Viral Pneumonia Confirm::.
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />CANT CONDITIONS-Condltlons contributing Mike death but not reediting in tie Underlying cause given in PART 1.
<br />26. IF.FEMALE:
<br />0 Not: pregnsntwtihln lawn year
<br />Pr42antst1imt:dideRdt:. �.
<br />hint iii+atIOE , butpn iyri.m wMNn 42 rays of death
<br />❑ Not prptant, but program 42 days to 1 year Wore death
<br />Uri.knows./(..prepuce Maude» mot year
<br />22,CDATE OF:tNNJURY (M*., Day, Yr.)
<br />22d. 1
<br />I IURY AT WORK?
<br />❑YES0 N.O._.
<br />21a. MANNER OF DEATH
<br />® Natural p;Homiolda:1. :. .::;:..
<br />Accident PsrtdinginImstigaVon
<br />❑ suicide ❑ Could not be diteminuif
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />❑ OtivaNOperator
<br />Passenger
<br />Pedestrian
<br />0 Other (specify)
<br />14b. REi ATIONSHW TO DE EbEfil
<br />Wife
<br />E (p
<br />DY4.2
<br />APPROXMATE INTERVAL
<br />onset to death'
<br />19. WA$ MEC?OAt E)kAMINLi "i'i''"
<br />O
<br />21d. WEREAliI
<br />TO COMPL
<br />❑ .'i
<br />22e. PLACE OF INJURY:Attiome6 ferm,:street, factory, ortip building, coast
<br />22a. DESCRIBE HOW INJURY OCCURRED
<br />2T31; (.Ot;A 1.* Kr STREEET6, NUMBER, APT.NO.
<br />23e. DATE t)FDEATH (Mo., Dey, Yr.)
<br />April 2$, 2020
<br />crra 'Ot,'11N ..
<br />23b. DATE SIGNED (Ma., Day, Yr.) 23c. TIME OF DEATH
<br />Mifr.9,>2020 02:08 PM
<br />Aid: f the e's . of my knowledge, death occurred at the time, date and place
<br />and Matta i cause() staid (signature and Title)
<br />Shaaib Z. Juneio, MD
<br />STATE
<br />4a C z,'-E SIGNED (Mc., Dey, Yr.!
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.1
<br />240, tilt the of examination and/or lnvsstigad
<br />paitkns, data and place and due to the cause(e),
<br />26 DIR: TOl1A000 U$E. CONTRIBUTE TO THE DEATH?
<br />No :in PROBABLY ❑ UNKNOWN
<br />2T:(NAMEF T17LE AND ADDRESS OF CERTIFIER (Type or Print
<br />5hosibZ Junejo, MD, 2620 W Faidley Ave, Grand Island, Nebraska,:68803:
<br />YES>
<br />26a. REGISTRAR'S SIGNATURE
<br />26a. HAS ORGAN OR TISSUE DONATION13
<br />❑ YES ;':' ::.. fa NO
<br />at-4eLll 8. 1-/L n a
<br />EN CONSIDERED?
<br />St Y OF FIiNDiNOSDEATAitittH?lLAE LB
<br />TE CAU$E
<br />NO..
<br />
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