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~ C Z 2 fi M N .. 0 � L; WHEN THIS COPY CAR1IWS THE RAISED SEAL OF THE NEBRASKA HEALTH SYSTEM IT CERTFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA TIM THE LEGAL DEPOSITORY FOR VITAL RECORDS' ` DATE OF ISSUANCE 4/6/2004 200406024 ASSISI LINCOLN, NEBRASKA HEALTH AND AA STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERV VITAL STATISTICS ripli? TTRTr A TT: r)F nP A T'T i co � M r, rn � o CS1 00 N C_.) U') 2. SEX o o -4 "t March 29, 2004 C D 5a, AGE - Last Birthday N �i 6. DATE OF BIRTH /Month. Day. Year) MOS. i DAYS M Grand Island, Nebraska O August 16, 1922 7. SOCIAL SECURTIY NUMBER Its., PLACE OF DEATH [K ❑ Home T HOSPITAL Inpa- OTHER: Nursing - -- o ❑ ER Outpatient ❑ Residence Bb. FACILITY - Name (Hnof insalufion, give street andnumber/ St. Francis Medical Center ❑ DOA ❑ Other(Specavi Br. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS t Grand Island Yes No ❑ r 9a. RESIDENCE - STATE Q) r 9d. STREET AND NUMBER /Including zip Code) 9e. INSIDE CITY LIMITS Nebraska CD o 1802 E. 6th St. 68801 Yes Q No El 10. RACE - (e.g., White. Black. American Indian. D 12. ❑ MARRIED FX WIDOWED N etc.) (Specify hispanic z MA ER DIVORCED E] � � 1 N 14a. USUAL OCCUPATION /Give kindof work done dwing most t4b. O$IEft -00 S[iPP t 03799 1. DECEDENT -NAME FIRST MIDDLE UST 2. SEX 3, DATE OF DEATH lMonM. Day. Year) Carmel Ray Martinez Male March 29, 2004 4. CITY AND STATE OF BIRTH ll1 not m USA.. name country) 5a, AGE - Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Year) MOS. i DAYS 5c. HOURS MINS. Grand Island, Nebraska (Yrs.) 81 5b. August 16, 1922 7. SOCIAL SECURTIY NUMBER Its., PLACE OF DEATH [K ❑ Home 505-18-5010 HOSPITAL Inpa- OTHER: Nursing - -- ❑ ER Outpatient ❑ Residence Bb. FACILITY - Name (Hnof insalufion, give street andnumber/ St. Francis Medical Center ❑ DOA ❑ Other(Specavi Br. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 8e_COUNTY OF DEATH - Grand Island Yes No ❑ Hall 9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including zip Code) 9e. INSIDE CITY LIMITS Nebraska Hall Grand Island 1802 E. 6th St. 68801 Yes Q No El 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) 12. ❑ MARRIED FX WIDOWED 13. NAME OF SPOUSE (d wife. give maiden name! etc.) (Specify hispanic IspeC�1 American MA ER DIVORCED E] 1 RIED 14a. USUAL OCCUPATION /Give kindof work done dwing most t4b. KIND OF BUSINESS INDUSTRY 1 15. EDUCATION (Specify only highest grade completedl Elementary or Secondary 10 -121 College 11 -4 or 5 -1 of working life, even /!refired) - - SectionTpan Railroad, Unim Pacific 9 16. FATHER -NAME FIRST MIDDLE LAST 17, MOTHER FIRST MIDDLE MAIDEN SURNAME Joseph Martinez Natalia Ramirez 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 190 INFORMANT -NAME - (Yes. no. or unk.( (If yes. give war and dates of services) I Jai, 5 �� -31, 1945 �I�IIOZ James Martinez Yes • 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) 2215 Maplewood Place, Grand Island, Nebraska 68801 20.E BA ER - SIIGGNN)ATURE IC NSE NO. 21 a. METHOD OF DISPOSITION 21b. DATE 21c. CEMETERY OR CREMATORY NAME 1071 ® Burial ❑ Removal April 2 , 2 0 04 , P 220. FUNERAL HOME -NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE All FAiths Funeral Home ❑crm pit ❑DOnahon Grand Island, Nebraska 221b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP( 2929 S. Locust St., Grand Island, Nebraska 68801 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a). (bl• AND (c)) 1 Interval between onset and death l f _ PART W Le 'e.k S lal DUE TO, OR AS A CONSEQUENCE OF, Interval oetween onset and death C: c-j� %�st1 '1 /twi b".'1j. DC Wa-Z-k'S @l DUE TO. OR AS A CONSEQUENCE OF: I Interval between onset and death 1 I (c) OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but no related P T PREGNANCY ART III IF FEMALE. WAS THERE A 124 IN THE PAST 3 MONTHS? AUTOPSY 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? PART / II i. d�U l� •�! 1 0 �h/ yyt �Q yy` t' 0 S I 7 V r (Ages 10 -54) Yes No Yes No Yes No 26a. 26b. DATE OF INJURY /Mo.. Day. Yr.) 260. HOUR OF INJURY 26d. DESCRIBE HOW IN, JRY OCCURRED Accident � Undetermined M Suicide Pending 26e. INJURY AT WORK 26f. E F INJURY - At home, farm. street. factory PUK ce building. etc. /Specify) 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ 27a. DATE OF DEATH /Mo.. Day. Yr.) 28a. DATE SIGNED /Mo.. Day. Yr) 28b. TIME OF DEATH March 29, 2004 M 27b. DATE SIGN' ED (Mo.. Day. Yr.) 27c. TIME OF DEATH g 2!!c. PRONOUNCED DEAD IMO.. Day, Yrl 28d. PRONOUNCED DEAD (HOUrI g '�GtC%t 11:45 P. M w= M 27d. 7o the best of my knowledge. death occurred at the time, date and place and due to the ,- � v 28e. On the basis of examination antl'or investigation, in my opinion death occurred at the time, date and place and due to the camels) stated. -T causets) stated. fi �/j l� yvl !1�1 �f� • O. (Signature and Title) ► ISi naNra and Title 29. DID TOBACCO USE CONTRIB 0 THE DEATH? �� 30.0 AS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? 1:1 NO ❑ UNK OWN- ❑ YES pr`t NC ❑ YES NO YES T 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) !Type or Pdnt) Jeffrey K. King, M.D. 729 N Custer Ave. Grand Island NE 6880 320. REGISTRAR 326. DATE FILED BY REGISTRAR *ft- Day. Yr-) 'I IV,&& APR - 5 2004 „- --