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<br /> WHEN TFNS COPY CARIZ�S 1ME RAISED SEAL OF THE NEBRASKA HEALTH ANQ#� �,R�$ N
<br /> SYSTEl1�fT CERT�IES Tlf BELOW TO BE A TRUE COPY OF THE ORIQ/NAL�%��_
<br /> THE NEBRASKA HEALTH AND HUMAN SERV/CES SY3TEM,VITAL STATIST!€.4
<br /> THE LEGAL DEPOSITORY FOR VITAL RECORDS. _= _ "� `-�'`
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<br /> MAR°�'�`�9� _ �.= -� ., .
<br /> !�� 109702 As.�sr� . . _
<br /> UNCOLN,NEBRASIUI HEALTH AND HIM� -
<br /> � STATE OF NEBRASKA-DEPARTMENf OF HEALTH AND HUMAN SERViC�$=F�,,�At�ip�!ORT
<br /> ViTAI.STA'I7ST[CS "�"„^�
<br /> CERTIFICATE OF DEATH
<br /> 1.OECEDENT-NAME FIRST MIDDLE LAST 2 SEX • 3.DATEOF DEATH /MOnM.Day.Yearl
<br /> Cerrovio N*4N Guerrero Male February 2E>, 1998
<br /> <.Ci7V AND STATE OF 81RTH /Mnoln USA..namg counhy/ Sa.AGE-Last Bitt�day UNDER 1 YEAfi UNDER 1 DAV 6.DATE OF BIRTH /MOnfh.Day.Yeai1
<br /> Wood River, Nebraska "'f5' 66 Sb MOS i DAVS SC.HOURS MINS Tuly 26, 1931
<br /> J 1
<br /> 7 SOCIAI SECURTIV NUMBER Ba PLACE OF DEATM "
<br /> 506-28-8969 HOSPITAL � InpatieM OTHER � Nu�S��qMOme
<br /> • - - -
<br /> Bb.fAGLITV-Name (Nno�mslilulan,give sbeel and numberJ � ER OWpatlent � Residence
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<br /> St. Francis Medical Center ❑ °OA ❑ ahe�r�,�,
<br /> & GTV.TOWN OR LOCATION OF DEATH Btl.INSIDE CITV�IMITS 8e.COVNTV OF DEATH
<br /> Grand Island �r= � Na ❑ � Hall
<br /> 9a.RESiDENCE-STA7E 9b.COUNTV 9c.C�TV.TOWN OR LOCAIION 90.STFEET.IFID NUMcER ;;r.du�:�Zy�Code; - . e �NSiDE CRV unnir5
<br /> Nebraska Hall Grand Island 321 N. Boggs 68803 �as�] No❑
<br /> �0.RACE-�e.g.,W�ite.Black.Amencan Intlian. 11.ANCESTRV le.g_Italian.Mex�can.German,etcl � 12.�MARRIEC ❑WIDOWED t 3.NAME OF SPOUSE llI wrle.grve marden name�
<br /> etc.11Scec�ryl ���'N) NEVER DIVORCED
<br /> Hispanic American MARR Susan Nova
<br /> 14a.USUAL OCCUPATION /Grve kmdo/wak done dunng mosl ��l1 14D KIND OF BUSINESS INDUSTRV �_O 75.EDUCATION �Specity only highes�gratle completed�
<br /> of wwkrng lAg.evBn d retiiedl �� ��" Elem n ry $eC ary I -12) CWlege I t.a or 5•i
<br /> General Laborer Railroad �.�t°� �ra�e
<br /> 16.FATHER-NAME F�iST MIDOLE LAS7 1' MOTHER �fIRST MIDDLE MAIDENSURNAME
<br /> Francisco �TNII�? Guerrero Ernestina :�11rIN Cantu
<br /> 18.WAS DECEASED EVER IN U.S.ARMED FORCES? �'Z_27_/O/ I9a.INFORMAN'-NAME
<br /> (Yes no.a unk.) pl yes.grve war antl tla�es ol services �t�
<br /> Yes Korean Conflict 12-26-51 I Susan Guerrero
<br /> 79b.INFORMANT MAILING ADDRESS ISTREET OR R F C NO_CITV OR TOWN.SfATE.ZIP�
<br /> 321 oggs Grand Island, Ne. 68803
<br /> 2C E EF-SICNATU EBLI NO r�� � 2ta METMOCOF[VSPOSI7�ON�21b.DATE 2�c CEMETERVOFCREMA70AV NAME
<br /> �! l U � �d��,a� �Remova� Mar. 2, 1998 Westlawn Memorial Park
<br /> 22a FUNERAL O �NAME 21tl CEMETERV OR CREMATOAV LOCATiON Ci�v OR TOWN STA7E
<br /> Livin ston-Sondermann F.H. I ❑Crematan ❑��a���, i Grand Island, Nehraska
<br /> 22b.FUNERAL HOME ADDRESS (STREET OH R.F.D.NO..CITV OR TOWN.STATE.ZIP�
<br /> 601 N. Webb Road, Grand Island, Ne. 68803-4050
<br /> 23. IMMEDIATE CAU IENTEfi ONLY ONE CAUSE PER LINE FOR ial.IDI.AND(c11 � Inlerva�between o�se a�tl tle h
<br /> yP/�RT /�� I
<br /> �\ lal �iVL�i. I � ���e
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<br /> � DUE TO.OR A CONSEOUENCE OF i irnervai ban+een onse�ane aeatn
<br /> , ��UG� '
<br /> Ibl �
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<br /> DUE TO.OR AS A CO E ENCE OF� lrnervai Denveen orset ana eeam
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<br /> OTF�l SIGNIFICANj�CONDITIONS-CmtliGOns contriWtirg ro ihe tleat�Dut rwt relatea PART ill IF FEMALE.WAS THERE A 2a AUTOPS� 25.WAS C/SE REFERRED TO MEDICAL
<br /> PART //�� /J_I/������� ,/, / � � /� PREGNANCV IN THE PAST 3 MONTHS9 �.. EXAMMEF OR CORONEA'
<br /> II �/ I C�, �.0�iii�� �i �✓"
<br /> r v (A9es�0-Sal Yes No Ves No Ves No
<br /> 26a. 26b DATE OFINJURV /MO..Day.YC/ 26c HOUF OFINJURV 26d DESCRIBE HOWINJURV OCCUARED
<br /> � Acatlern � Undeterminea M
<br /> � SmoAe � Perxl�ng 2fie.INJURV AT WORK 26t PLqCE QF iNJURV�/U hqne,larm.streeL�actory 26g.LOCATIpN STREET OR RF D.NO. CITV OR TOWN STATE
<br /> ❑ a Q -olfice Cu�Ming etc /Specryl
<br /> HomitWe Investgaum Vas NO
<br /> 27a DA7E OF nOEATH /MO Day.�� 28a DATE SIGNED /Mo.Day Yr I 28b TIME OF DEATH
<br /> z 1-� Ol ��'� ��'„ M
<br /> �r - 27b.DATE SIGNED (MO_DaY/Y�_! 27c TIME OF DEA7H Q�� 2Bc.PRONOUNCED DEAD /MO.Day Vr./ 28tl.PRONOUNCED DEAD /HOUiI
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<br /> °Q 27tl.To�I�B DBS�01 my krbwlBtlqe.De al Ihe lime,tle�e antl plate e to 1� °�° 2Be.On the basis d ezam�naaon ana or invesugation,m my opnan tleaih occurreC ai
<br /> \c a uselsl stated. - the�ime,dale antl piace ana tlue io t�e causelsl stated.
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<br /> �9 naWre arM iitle► �S�nature an0 iitle�►
<br /> 29.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30a HAS ORGAN OR TISSUE DONATION BEEN CONStDERED7 30.b WAS CONSENT GRANTED7
<br /> � �VES � NO � UNKNOWN �� � VES �NO � � VES �NO
<br /> 31.NAME AND ADDRESS OF CEFTIFIER IPHVSICIAN,COHONER'S PHVSICIAN OR COUNTV ATTORNEV I lType a Prin!l
<br /> �' iC r . l'YU eh l- ��� - . �.�1 /�< ��o o r�z /S d �tl� l��'03
<br /> 32a REG�STRAR 32D �A7E FiLED BV REGISTRAR /MO..Day Ycl
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<br /> - � �NAR 6199�
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<br /> '-L'ot Six (6) , in Block Fifteen ( 15) , in Packer and Barr' s Addition to
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