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<br />STATE OF NEBRASKA
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<br />WHEN tHis COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />SEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />PA7EOPISSUAlI 01.CE
<br />• 7/16J2026
<br />UNCOLN, NEBRASKA
<br />•
<br />2026048Q7
<br />� + 061,11-4407,lt
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMJN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 DECEpENT`3.'.11AME (FIT*, Middle, Last, Suffix)
<br />Ar ton)a 'be Paxtle
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Mexico
<br />f. SOCIAL<SECURITY NUMBER
<br />MBER
<br />506-43 1328
<br />8b.FACILITY-NAME (If not Institution, give street and number)
<br />CHI Health St Francis
<br />8c CITY GE TOWN OF DE#. FH (include zip Cods)
<br />Grand Island 68803
<br />91. RES10ENCESTATE
<br />Nebraska `:
<br />Sd.::STREET AND: NUMBER
<br />�1022 Ufi 7th Street
<br />9b.000NTY
<br />Hall
<br />10s. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Marled
<br />❑ Married, but separated iTi Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S NAME (First;: Middle, Last, Suffix)
<br />Aurelio Pa1oma Alonzo
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) No
<br />t.6. MFTCD OFI ISP SS;LTJON
<br />igkMurM [,] Dtmattitt
<br />❑ cremation:. ❑ Entombment
<br />❑ Removal ❑ Other (Specify)
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />75
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand'Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH IMO.,
<br />August 20, 2024
<br />6. DATE OF S IM (Mo., Day, Yr.)
<br />March 2, 1
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (&ruty)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Ye. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />lg. INd4DE;:CITY LIMITS>
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) N wife, give maiden name
<br />Adolfo Paxtle Rincon
<br />12. MOTHER'S -NAME (First, Middle, Maiden Sumime)
<br />Delfina Ramirez Garcia
<br />14a. INFORMANT -NAME
<br />Adolfo Paxtle Rincon
<br />16a. EMBALMER -SIGNATURE
<br />Kelley D Sheridan
<br />16b. LICENSE NO.
<br />1439 /
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />170.:FUNERAL tHOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />' CAUSE OF DEATH (See instructions and examples)
<br />1 . PART I. Enter the chain of events- Aisaans, injuries, or compiiationa.that directly quad the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory aneat, Of ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />WIKt601ATE CAUSE {Final a)cardio respiratory failure
<br />0.00.6 Or Candttion resiiiltrig
<br />in death)
<br />>iequerdieby bat condtttone N
<br />anyriudhipto th0 reuse 1htd.
<br />onma:a
<br />Eris t S UNDERLVAIG CAUSE
<br />(disease or injury that initiated
<br />1M events resulting hi death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) malignancy
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 PART ti. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Z(I iF FEMALE; .:
<br />❑ Nat pni9iiaat klaiM pfast y�y
<br />PregMita t luua of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />©: Wiknow*VI Hpr gnant wahh :lM pat year
<br />32a. DATE:OF INJU
<br />510.4 Day, Yr.)
<br />22d. INJURY AT WORK?
<br />:DYES CjNO
<br />2
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />❑ Paanger
<br />❑ Pedestnan
<br />❑ Omer (Specify)
<br />14b. RELATION$ IP TO D
<br />Spouee
<br />16c. DATE (fda Day Yr
<br />Au31ust 2%1.4024
<br />onset
<br />all
<br />.r
<br />19. WAS MICA( UAMt
<br />OR CORONER: CONTACTED?
<br />❑ vas ...:.s►o
<br />21 c. WAS AN AUTOPSY PERF
<br />❑ YES to
<br />2Id. WERE AUTOPSY FtNDQ G$ AVALLASLS
<br />TO COMPLETE CAUSE OF.BEATH?
<br />❑YES
<br />22e. PLACE OF INJURY -At home, fann, street, factory, office building, cons
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />VON OF INJURY- STREET & NUMBER, APT.NO. CITY/TOWN
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />August 20, 2024
<br />23b DATESIGNED.(Mo., Day, Yr.)
<br />Audust21 2024
<br />23c.1WE OF DEATH
<br />04:48 PM
<br />*2d To iht bat otmy 10now1edb*, death occurred at the time, data and place
<br />and`due to ttw causes) stated. (Signature and Title)
<br />Anup V. Sura, MD i
<br />-STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24e. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24d. TIME PR
<br />24e : on the basis of examination limt/or investigation, in my
<br />the time, date and place and due to the aues(s) stated. Ogg
<br />*DID TO 73ACCr USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DO TtON BEEN pONSIDEED?
<br />❑:YES NO 0 PROBABLY ❑ UNKNOWN 0 YES El NO
<br />27NAME, Tin D ADDRESS OF CERTIFIER (Type or Print
<br />Anup V. Sura, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />26b. WAS CONSENT GRANTED
<br />Not Applicable if 26e is NO
<br />28b. DATE FILED BY REGIS'
<br />August 23, 2024
<br />ED a
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