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02/13/2004 15:58 FAX.9139050810 PRINCIPAL RESIDENTIAL <br />200402390 <br />[a 002 <br />Wp EN THIS COPY CA RFWS TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVCES <br />SYSTEM!, R CERTwE 5 THE BELOW TO BE A TRUE COPY OF THE OR►GlNIAL: RECORD AN. FIL €WITH <br />THE NEBRASKA HE11 LTH AND HUMAN SERVICES SYSTEM, VITAL is <br />THE LEGAL DEPOS! TORY FOR VITAL RECORDS. _ <br />DATE OF ISSUANCE <br />r ANILEICS, CoOPaER =: <br />6/27/2003 A s=TANr srA&; iEGISymq <br />LINCOLN, NEBRASA A HEALTH AND HUMAN SERVICES SYSTEM_ = <br />ST. \TE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES .FINAjkM ANII.$UPPCIRT <br />CERTFICATE o D EATH - -- -_ - -0 3 07139 <br />I. DECEDENT -NAME FIRST MIDDLE UST <br />Z SEX <br />3. DATE OF DEATH IMaeth OAF VOW <br />Dai.iel Patrick Monroy <br />Male <br />June 13, 2003 <br />CITY AND STATE OF BIRTH 74 1W k1 US 4- n4na cvunl➢1 <br />SL AGE -Lao B"Nday <br />U:NOER 1 YEAR <br />UNDER 1 DAY <br />8. DATE DFBIRTH IMaIA Oay. Yau) <br />sb.MOS. DAYS <br />ScHOURS' wNs. <br />San Antonio, TE.xas <br />NMI 62 <br />March 17, 1941 <br />7, SOCIAL 3ECURT1Y NUMBER <br />Be. PUCE OF DEATH <br />HOBwTAL ❑ "liars OTHER: ❑ N.MHit. <br />389 -36 -5849 <br />❑ ER Owpodawo ® Rosdw= <br />Bb FAC6JTY•Nartr for >I ialiAdidM1 pre air" andnumwy <br />� <br />1 4026 Edna Drive <br />❑ °OA ❑ O°°r('�A/ <br />ac, CITY. TOWN CA LOCATION OF DEATH <br />Bd INSIDE CITY LIMITS <br />Ba. COUNTY OF DEATH <br />Grand Island <br />. w: [A Ne ❑ <br />Hall <br />Oa. RESIDENCE -STATE ub. COUNTY liG CITY, TOWN OR LOCATION d STREETAND NUMBER M1bMdnD Zb Coda! h. INSIDE CRY LIMITS <br />Nebraska Hall Grand Island Edna Drive Yea © No ❑ <br />194026 <br />1D RACE - la.g.. Whae. Black Alnarldn LIMBO, 11. ANCESTRY le.g.. aaBen. Marican. Garman, MO 12 •® MARRIED ❑WIDOWED 13. NAME OF SPOUSE A7 calla. Elva neieM nsme( <br />American isp.cdr) Mexican NEVER DIVORCED Carrie Difatta <br />1 11 MARRIED F <br />IAL USUAL OCCUPATION /Give Midc(w,*dwwdL0vnaocl 14K <br />KIND OF BUSINESS NDIISTRV I <br />1S. EDUCATION <br />( SA •cav'onlyhighatlgradecomplal•d) <br />Hemenlwy or Secrdary 10.14 CDUe (1.4 w S -I <br />doii All A aw l warad) <br />Information Secv.rity Office <br />Veterans Administration <br />12 <br />IL FATHER -NAME FIRST MIDDLE LAST 17, MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Jaime Monroy I Josephine Martinez <br />R! WAS DECEASED EVER 1N U.S. ARMEI' FORCES? z8 1 60 <br />(rya. •a. ar , Id yaa give . and daua a yrvioag♦ L <br />47 9 <br />Ift NFORMANT -NAME <br />. l <br />Yes: V' tnam War: 1����� (?f CJ 3 <br />Carrie Monro y <br />12k INFORMANT MAILING ADD iESS /STREET OR R.F.D. NO, CITY OR TOWN. STATE ZIP) <br />4026 Edna Drive, Grand Island, Nebraska 68801 <br />2(L EMBALMER• SIGNATURE B LICENSE M L <br />21 a METHOD OF DISPOSITION <br />211L DATE 21c <br />CEMETERY OR CREMATORY NAME <br />./� <br />©B,,;r ❑R.IaAVa( <br />June 18, 2003 <br />Ft. McPherson National <br />Zb. FUNERAL MIME -NAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Apfel- Butler- Gee.des <br />Maxwell, Nebraska <br />22Ja FUNERAL HOME ADDRESS (S7 RErr OR R.FA. N0. c" OR TOWN. STATE, ZIP) <br />1123 West Secoi:d, Grand Island, NE. 68801 <br />2i IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR hl. B71• AND Iq) I Interval beivisen anal and dear" <br />PART <br />Ilat Cardiac arrest I immediate <br />I <br />DUE TO, OR AS A CONSEOUENCE DF• 1 Interval b•hvean areal and death <br />) <br />B4 i <br />DUE TO, OR AS A CONSEOUENCF OF. I 4darval bal•iean ena•I and dean <br />1 <br />I <br />�cl I <br />OTHER SIGNIFICANT CONDITION, - Ca1dNaln caFU&da g d dta dmM bul nn(raloled <br />PART R IF FEMALE, WAS THERE A 24 <br />AUTOPSY <br />2E. WAS CASE REFERRED TO MEDICAL <br />PART <br />PREGNANCY N THE PAST 3 MONTHS? <br />EXAMNER OR CORONER? <br />a <br />pAgsatD -ba) Yea. Ne <br />nee Nb <br />Yo FA No <br />26a <br />2E4 LATE OF INJURY (Sir., pray- vrJ <br />alit HOUR OF WJURV <br />DESCRIBE HOW INJURY OCCURRED <br />Add" Ej Ureiew"dned <br />f <br />126d. <br />M <br />El Suicide 0 P g <br />Me. INJURY AT WORK <br />26L PACE °F NJ� - N hang. farm, e* W. factory <br />2%. LOCATION STREET OR RF.4 NO, CITY OR TOWN <br />' ❑ Haakwo w",dpalon <br />(a ❑. me ❑ <br />DIdMJnLL /SParJD'l <br />... . - <br />27L DATE OF DEATH /Ma Day A) 211a. DATE SIGNED 041 ,DIgL YCN 21d TIME OF DEATH <br />9:30 pm <br />M <br />alC <br />27R DATE SIGNED l -Gap. Y:1 27e TIME OF DEATH 28c. PRONOUNCED DEAD (Ab.. ay. Al ltd PRONOUNCED DEAD (H.W <br />€ M June 200 ( j 110: 51 pm M . <br />B <br />27d To the heal at r1y arlvu6dg•, feats scuretl At the Brrla data srd place and due to dI• Ma On the baei t •a neeon arAd. a N dwlh exund at <br />eaA wAd Sued. ! the Bma, <br />I - <br />IS alum And TBa 1 mitme - <br />2a Oro TOBACCO USE CONTRIBUTE TO T NE D��EyA1TI-17 >CA HAS ORGAN OR TISSUE DONATION BEEN CdJS10 EDT NT ' E0T <br />❑ <br />❑ YES ❑ NO U UNKNOWN ❑ YFd3 NO YES NO <br />31. NAME AND ADDRESS OF CERTIFIER I M'SICIAN, CORONER'S PHYSICIAN OR OOUNTY ATTORNEY? fyWW f P" <br />Sgt D Dubbs, GIPD,.131 S Locust, rand Island, NE 68801 <br />32L REGISTRAR <br />326. DATE FRED BY REGt$Ti l 2 Ltry N 003 <br />J 1` 6 <br />