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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTFU IT CERTIFIES THIS BELOW TO BE A rOf 1= COPY OF THE ORIGINAL RE O <br />C RD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS 200311406 <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS, <br />DATE OF ISSUANCE = _ <br />q <br />4tAWNLEYS. COOPER <br />;J� <br />OCT 5 2001 ASSISTANT STATE REGISTRAR <br />LINCOLN, NEBRASKA HEAL AND HUMAN SERVICES SYSTEM <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT <br />VITAL. STATISTICS ^ l f ^ R <br />CERTIFICATE OF I)F.ATN t j <br />1 DECEDENT NAME FIRST .MIDDLE - LAST <br />2 SE.X 3 DATEOF DEATH ,Alo"m&N YearU_ <br />Cecilia Marie Nason <br />Female October 2, 2001 <br />A. CITY AND STATE OF BIRTH 111not n US.A. riameeouney) <br />Sa. AGE -Last Birthday <br />UNDER 1 YEAR <br />UNDER I DAC <br />6. DATE OF BIRTH /Money. Da, Year) _ <br />Lexington, Nebraska <br />(Yrsl <br />63 <br />SD MOS DAYS <br />Sc HOURS MANS <br />November 22, 1937 <br />7 SOCIAL SECURTTY NUMBER <br />Be PLACE OF DEATH -- -- <br />362 -36 -2431 <br />H__O_SPIT_A_L © Inpatient OTHER ❑ Nursing Home <br />❑ ER Oulpalient ❑ Resldarycn <br />BO FACILITY - Name lernot- hereon, glva skew and numoej <br />BryanLGH Medical Center East <br />❑ DOA ❑ OtherISoe,el -y <br />SC. CITY TOWN OR LOCATION OF DEATH <br />Bd. INSIDE CITY LIMITS <br />Be COUNTY OF DEATH _ <br />Lincoln <br />Yes k] No ❑ <br />Lancaster <br />9A RESIDENCE - STATE <br />9b COUNTY <br />9c. CITY. TOWN OR LOCATION - <br />90 STREET AND NUMBER /lrx ludvg Zip Code! <br />9B INSIDE CITY UA+ <br />Nebraska <br />Hall <br />Grand Island- <br />3131 W. 15th St. 68803 <br />Yes KI r <br />Y „ <br />10 RACE - Is 9. White. Black American Indian <br />11. ANCESTRY le.g Italian. Mexican. German, etc) <br />l2. ® MARRIED ❑WIDOWED <br />-l. <br />— <br />13 NAME OF SPOUSE /e w•fe IM'e rrnar�rr name! <br />etc I fsow yl <br />Hispanic <br />ISPeafY) <br />I Mexican /American <br />NEVER DIVORCED <br />John Nason <br />14a USUALOCCUPATION (Gave keldd work done disrtlg most <br />"`If KIND OF BUSINESS INDUSTRY <br />_ <br />15 EDUCATION ( Specayonlyh ,gheStrpaclecompteted) <br />d workeyq h* ~ erehredU <br />Sales <br />Retail Furniture Sales <br />Elementary or Secondary 10121 Cc" 11 a I. 5 b 1 <br />I Unknown <br />16 FATHER - NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MIDDLE MAIOEN SURNAME <br />Juan Cantu, <br />Conception Guerrero <br />IB. WAS DECEASED <br />EVER IN U.S. ARMED FORCES? <br />196. INFORMANT - NAME <br />'Yes. no. or unk.l <br />M yes give war, and dates of servidesl <br />- <br />No <br />I <br />John Nason Sr. <br />190 INFORMANT - MAILING ADDRESS ISTREET OR R.F D. NO.. CITY OR TOWN. STATE. ZIP) <br />3131 We 15th St., Grand Island, Nebraska 68803 <br />20 EMBALMER - SIGNATURE a LICENSE NO <br />21a METHOD OF DISPOSITION <br />210, DATE 11 21C <br />_ <br />CEMETERY ORCREMATORY -NAME <br />®Buhl ❑AmoYal <br />I <br />Oct. 5, 2001 L <br />Westlawn Memorial Park <br />22a FUNERAL HOME - NAME, <br />21d CEMETERY ORCREMAtORY LOCATION CITY OR TOWN. STAID <br />Livingston — Sonderman Funeral H <br />Cremation ❑Donatw <br />Grand Island Nebraska <br />220 FUNERAL HOME ADDRESS ISTREET OR R,F.D. NO CITY OR TOWN. STATE. ZIP) <br />601 N- Webb Rd., Grand Island, Nebraska 68803 -4050 <br />23 IMMEDIATE CAUSE IENTEH ONLY ONE CAUSE PER LINE FOR 1a1. 101. AND (c)1 Interval hetween ons.a :,w2 I•, <br />PART <br />p <br />' d`lXrl d C �Y 2r`, N.1.1 K a QS <br />1al <br />DUE TO. OR AS A CONSEQUENCE OF - <br />�^ / ` Inerval hewveen msa and d� .ru. <br />10) n J'f'-Q- l 52Q -S- 2,GL 0' S <br />DUE TO. OR AS A CONSEQVENCE OF fn1 at balween ousel :end nr.y1 <br />I <br />10 <br />PART OT ER SIGNIFICANT CONDITIONS - Conditions ConlriOAng b the death Out nd rNaled PART 111 IF FEMALE. WAS THERE A 71 AUTOPSY 25. WAS CASE REFERRED TO ME DIr. <br />PREGNANCY IN THE PAST 3 MONTH EXAMINER OR CORONER <br />II a c'I � l o. X i S (Ages 10 -SAL Yes No Yes No Y6s.0 <br />_ <br />?6a DATE OF INJURY IMO.. Day Yr.) 28c HOUR OF INJURY MOW INJURY ,CUIa?f U <br />' <br />1211t[DESCRIBE <br />F1 Accxlerll F] Undetermined . <br />M <br />Sucrcle [–] Pending <br />26e. INJURY AT WORK <br />20 <br />WC EE O INJURY At home. farm street factory <br />./Spw / <br />26g. LOCATION S1 RFE t OR R F.D. N0 CITY OR TOWN $ I A I I . <br />H—cde Ifwesgaor <br />Yes 1:1 No ❑ <br />27a DATE OF DEATH IMO Day YrJ - <br />28a. OATS SIGNED (MO Rai, Yr I <br />280 TIME OF DEATH <br />OG <br />a� <br />270 DATE SIGNED /Ab. Day Yi) <br />27c TIME OF DEATH <br />2k. PRONOUNCED DEAD IMO. Day, Yr.) <br />28d. PRONOUNCED DEAD lllanl <br />2 zoo' <br />f % <br />Oz T M <br />w� <br />M <br />I <br />27d To ate Oesl ol my occurred at,te tkne, date and dace and due to the <br />2Be. On The Oasis of examination and or nvesi gation, m my opinion death occurred at <br />o <br />° <br />ewewsl staled. <br />u O <br />the time, daft and plate and due 10 dft caul lsl Staled. <br />1 tare and Tit e <br />S e and Title) 10 <br />29 DID TOBACCO USE CONT141ULLM TCFTVE DEATH? <br />a HA R AN OR TISSUE DONATION BEEN CONSIDERED' <br />_ <br />300 WAS CONSENT GRANTEO1 <br />❑ YES NO El UNKNOWN <br />V YES ! ❑ NO - <br />❑ YES I K NO <br />K `� <br />31 NAME ANO ADDRESS CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY A ORNEYI !Type I» PrmO <br />L� L I I 'r.%-: JAI OJ,L�� ' c <br />M. � .i� l <br />32. REGISTRAR <br />32n UAiE FILED RV REGISTRA /MO Dar Yrl <br />�( OCT 4 NO-) <br />he'eii'y' rC -! -1 f'y' 1hIS ti hp a trt!e and Guirec, copy of the orl�lna <br />fi ed w Lh �L,h; State of ,� brasna <br />ku <br />Signed in my prey day of <br />�_..._N0t'3,,yPu!,,i'1C <br />HEtAV L <br />GENERAL NOTARY -State Of Nebraska <br />TERR L. LoSG <br />MY Comm. Exp. - <br />