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WHEN THIS COPY CARRES TFE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN Sl SYSTEAC R CERTiFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORAt" THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST1C8_8E=! THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 6/3/2003 200M789 ASSISTANT -40, LINCOLN, NEBRASKA HEALTH AND Hll SFFiI► STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FiIJI VITAL STATISTICS CERTIFICATE OF DEATH WITH CH IS r a� n�n9� 1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 's + 3. DATE OF DEATH /Mann. Day. Year) Francisco NMI Martinez Male L May 26, 2003 4. CITY AND STATE OF BIRTH td not In U.S.A.. name counay) (Ages 10 -54) Yes No Sa. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH tMonft Day. Year) Sb. MOS. I DAYS 5c. HOURS' MINS. Sweethome, Texas "Y" 78 O January 30, 1925 7. SOCIAL SECURTIY NUMBER Suicide Pending Be. PLACE OF DEATH 26f. PLACES QFF,� UUCRY - ho � , farm. street. factory = 451 -24 -2183 Homicide Investigation t2 -_TAL ❑ Inpatient OTHER Nursing Home ol8ce I ❑ ER Outpatient ❑ Residence 8b. FACILITY -Name /l/no insktUaorr. give seeet and number) VAMC, Grand Island 28a. DATE SIGNED (W... Day. Yr.) ❑ DOA ❑ Other /Spec - "I Sc. CITY. TOWN OR LOCATION OF DEATH - 8d. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand Island 27b. DATE SIGNED /Mo.. Day Yr/ Yea K No ❑ Hall I 9a. RESIDENCE -STATE 9b. COUNTY May 27, 2003 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER tncludirg Zip Code) 9e, INSIDE CI7V LIMITS Nebraska Hall 28e. On the basis of examination and,or investigation, in my opinion death occurred at the time, date and place and due to the cause(sl stated. Si nature and Title) Grand Island 1223 E 22nd, 68801 Yes No ❑ ® 10. RACE - (e.g., White. Black. American Indian. 11. ANCESTRY (e.g.. Italian. Mexican. German, etc) 12. MARRIED yy ❑ WIDOWED 13. NAME OF SPOUSE /ll wile. give maiden narnti) etc.)ISpe "IyIHispanic 'S°8C ") Mexican 0=. DIVORCED jeOna, Fief 14a, USUAL OCCUPATION (Give kind of work dare during most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Specify only highest grade completed) Elementary or Secondary 10 -12) College 11 -4 or 5 -1 5 of working life, even if retired) Nursing Assistant Medical 16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME (Dec) John Martinez 1 (Dec) Andrea Gomez 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT - NAME (Yes. no. or unk.) (It yes. ive er ates s) Yes _W - 19b. INFORMANT MAILING ADDRESS (STREET OR R.F.O. NO.. CITY OR TOWN, S 1 A I L. LIP) 223 E 22nd Grand Island Nebraska EMBA ER - SIGNAT LIC NS 21 a. METHOD OF DISPOSITION 21b. DATE ;21c. CEMETERY OR CREMATORY NAME WeStlawn � 8urial E] Removal emorial Park Cemetery 22a. UNERAL HOME NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Kleine Funeral Home ❑ Crem~ ❑ Donation Grand Island 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 3213 W North Front St Grand. Island Nebraska 68803 23. ry IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la). (b). AND (cl) I Inteal between onset and death PART I )(a) Cardio - Respiratory Failure DUE TO, OR AS A CONSEQUENCE OF Interval belvroen onset and death I (b) Anorexia Few Months DUE TO. OR AS A CONSEQUENCE OF: Interval between onset and death ' I (c' 1 - ------ 1 __r,x1 __y • 11.11 VIK.Y.14�..- 1 \/\J1 V1 V \.. V VVV14J OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART PART PREGNANCY III IF FEMALE. WAS THERE A IN THE PAST 3 MONTHS? 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL EXAMINER OR CORONER? Weight Loss (Ages 10 -54) Yes No Yea No Yea No 26a. 26b. DATE OF INJURY (Md.. Day Yr.J 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident � Undetermined M Suicide Pending 26e. INJURY AT WORK 26f. PLACES QFF,� UUCRY - ho � , farm. street. factory = 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ❑ No ❑ ol8ce I 27a. DATE OF DEATH (Mo.. Day. Yr.) � 28a. DATE SIGNED (W... Day. Yr.) 28b. TIME OF DEATH �< May 26, 2003 0 �C air M 27b. DATE SIGNED /Mo.. Day Yr/ 27c. T)ME OF DEATH 28c. PRONOUNCED DEAD JW. Day, Yr.) 28d. PRONOUNCED DEAD (MOUrI May 27, 2003 1030 PM 8 M 27d. To the best of my know /edge. death occurred at the time. date and place and due to the Cause(=/ stated. (Signature and Tnle) ► ((�I -� "�� ' "- r 28e. On the basis of examination and,or investigation, in my opinion death occurred at the time, date and place and due to the cause(sl stated. Si nature and Title) 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH' 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED? ❑ YES ❑ NO Ys' UNKNOWN ❑ YES [ f NO ❑ YES ❑ NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI /Type o Pnnt) Karuna Gaddam MD Nebraska /Western Iowa HCS 2201 N Broadwell Grand Island NE 68801 32a. REGISTRAR 32b. DATE FILED BY REGISTRAR (Ma. Day. Yr.) JUN 2 2003 '-----A'* N' w-"V"`V