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c M N CA <br />O n Z _ <br />6 n D .N. <br />Q <br />>�6 <br />6' <br />�p <br />W <br />3 5 U 3 <br />C=D-! N <br />rrt O <br />M } �7 < 0 <br />© O <br />o T D Uzi <br />O <br />cn <br />rn -n r <br />o 17 n w <br />rn Cf) <br />c,o 7 w N <br />D N <br />Z <br />4 <br />OPTIONAL FORM 180 <br />(Rev.12 200403320 <br />(FORMERLY Y FS -192) <br />DEPT. OF STATE <br />50180 -103 Report of Death of an American Citizen Abroad <br />Tijuana,Mexico, 31- Jan -2001 <br />(Post date of issue) <br />SSA No. 623 -14 -4859 <br />Name in full Juan Ramon Juarez Pineda Age 38 <br />Date and Place of Birth December 24, 1961 Mexico City, Mexico <br />Evidence of U.S. Citizenship Naturalization Certificate 24587049 issued January 1, 2000, OMAHA, NE <br />Address in U.S.A. 4006 Reed Rd., Grand Island, NE USA 68803 <br />Permanent or Temporary Address Abroad <br />Date of death October 11, 2000 08:30:00 <br />Place of Death TIJUANA, BAJA CALIFORNIA, MEXICO <br />(Number and Street) or (Hospi'al nr hnten - <br />Cause of death ANOXEMIA DUE TO STRANGULATION <br />(Including authority for statement - if physician, include full name and official title, if any) <br />as certified by Dr. Mercedes Quiroz Prado, I.D. 1474070 <br />Disposition of the remains LOCAL <br />Local law governing disinterment of remains provides that <br />Remains may be disinterred after five years <br />Disposition of the effects N/A <br />Person or official responsible for custody of effects and accounting therefor N/A <br />Traveling /residing abroad with relatives or friends as follows: <br />NAME ADDRESS <br />Not Applicable Not Applicable <br />Informed by telegram or telephone <br />NAME ADDRESS D <br />Maria Juarez 4006 Reed Rd., Grand Island, NE USA 68803 11 <br />Copy of this report sent to: <br />NAME ADDRESS <br />Maria Juarez 4006 Reed Rd., Grand Island, NE USA 68803 <br />D <br />31- Jan -2001 <br />o, <br />Z <br />3 <br />A <br />4 <br />G <br />N <br />n <br />N <br />ro <br />r <br />a. <br />w <br />4 <br />G <br />a <br />w <br />0 <br />- <br />Notification or copy sent to Federal Agencies: SSA x VA CSC Other <br />(State Agency) <br />The original copy of this document and information concerning the effects are being placed in the permanent files of the Department 0 <br />of State, Washington, D.C. 20520 n <br />Remarks: U.S. Certificate':of Naturalization No. 24587049 seen and returned to Mrs. Maria Juarez. a <br />(wife). <br />N <br />O <br />O <br />O <br />(Signature on albc ies) <br />[SEAL] Gloria Laguna o <br />Vice Consul of the United States of America. o <br />Certified copies available from: Correspondence Branch, Passport Services <br />Department of State, Washington, D.C. 20520. First Copy $20, additional copies $10.00. <br />.SCE <br />- _ - � i <br />WII <br />