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<br />.. WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSn:~ "CERTlFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILl! WITH <br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STA nsnca SECTiON, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~... _1. . -.. ~~ . <br /> <br />DA TE OF ISSUANCE fl. <br />0510817 M~aroonR <br />1 /21 /2005 2 0 ASSISTANT STATE REGISTRAR <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM <br /> <br />STATE OFNEBRASKA-OEPARTMENTOFHEAL11fANDHUMANsaVlCES FINANCE AND SUPPORT 14651 <br />' VITAL STAnsnCS, 0 4 <br />CERTIFICA TEOF DEATH - <br />FIRST MIDOlE LAST 2. SEX 3. DATe OF DeATli 1_, o.y. Y-J <br /> <br />,. DECEDeNT. N"ME <br /> <br />..,. F..CIUTY. Nome <br /> <br />1M not mstituliM gi.. s/fHIl/fId ~ <br />John St. <br /> <br />lla. PlACE OF DEATH <br />. HOSPITAL 0 ~ <br /> <br />DEA~ <br /> <br />DDOA <br /> <br /> <br />December 30 2004 <br />e. DATE OF BIRTH 1_ o.y. YN<j <br /> <br />september 16, 1914 <br /> <br />Louise <br />'. CITY AND ST"TE OF BIRTH IMfI(J/"U.s'A._C,."..,,1 <br /> <br />Leon Guanajuoto, <br />7. SOCIAL secuRny NU"BER <br /> <br />Mexico <br /> <br />',Frances Moreno <br />50. AGE, l.ulllHlday UNDER 1 YEAR <br />rv...1 9 0 51>. l,tOs. I DAYS <br /> <br />Grand Island <br /> <br />9a- RESIDENCE, ST.. TE <br /> <br /> <br /> <br />OTHER 0 NUf5olog Home <br /> ~ Rtlltdenc:. <br /> 0 0tN'/S-1i>/ <br /> <br />505-52-7390 <br /> <br />2924 w. <br /> <br />8c. CITY TQYffl OR lOC"TION OF DEATH <br /> <br />Ill. INSIDE CITY UMlTS N. COUNTY OF DL\TH <br /> <br />Nebraska <br /> <br />'0. R..ce -(0.\1-. _. Block, American Indian. ". "NCESTRY 1..g..ltolIon. ....ocon. Gtmlan, oIel <br />IO;.IIS-:,jyl.. ISOtCIIy! <br />H:i..spanic <br />'.. USUAl. OCCUP..TION Iw,,"kmol"""*<iOned<Jnngmost <br />oI_*._;t_, <br />Homemaker Own <br />16, FATHER - ......E FIRST ..,DOLE LAST <br /> <br />ItIcIWIng ~ ea., Ile INSlOE CITY L1"ITS <br /> <br />John st. 68803 v.. 6tJ No 0 <br />la. NAME OF SPouSE IM_,g;.._IlOmO' <br /> <br />MAlOEN SURNAME <br /> <br /> <br /> <br />Vincent'Moreno <br /> <br />ISTREET OR RF.O. NO.. CITY OR TOWN. ST"TE. ZIPl <br /> <br />522W. 2nd St., Grand Isl.nd, Nebraska <br />210.lAETHOOQF tIlSPOSITION 21b. DATE <br /> <br />6 880 1 <br /> <br /> <br />21<;. CElAmRYORCRE....TORV N.....E <br /> <br />'1328 <br /> <br />liJ IIIMioI 0 _01 Jaruay;3, 2005 G:rard Island city Ca:lE!teq <br />214 CElAmRYORCRl;IU.TORYLOCATIQN CITVORTOWN ST..re <br />D~ D- Grand Island, Nebraska <br /> <br />All Faiths Funeral Home <br /> <br />221>. FUNERAl. HO..E "DDRESS <br /> <br />ISTREET OR "-F.D. NO.. CflY OR TOWN. ST" TE. ~Pl <br /> <br />2929 S. Locust St., <br />23. _llIATE CAUSE <br />PART <br />I <br /> <br />'" <br />DUE TO. OR "S .. CONSEOUENCE OF <br /> <br />u <br /> <br />~r_an~_Js_la~g ~ N",br.aaka_ ---68eO 1 <br />IENTER ON~ Y ONE CAUSE PEA FOR 11l.lb\. AND (CD <br /> <br />""""01_ onSOI and ...'" <br /> <br /> <br />Inter..... ~ onset aM aUI/'! <br /> <br />11>1 <br />auE TO. OR "S .. CONSEOVENCE OF, <br /> <br />tnMrval between orl$f!II ana <Mag, <br /> <br />lei <br />OTHER SIGNIFICANT CONDITIONS - C<romons ~ lD Iho dealnllul "'" ,_ <br />PART <br />. <br /> <br />2lla <br /> <br />281:>. 0" TE OF INJURY ,Mo.. D.ly. Yr.' 2ec:. HOUR OF INJURY <br /> <br /> <br />2lIg. l.OCAT'IOH <br /> <br />STREET OR RF.O. NO. <br /> <br />CITV OR TOWN <br /> <br />ST"TE <br /> <br />o Accooono 0 U_""noo <br />o Suocodo 0 P"""""I 260. INJURV" T WOR~ <br />0- In_1I(In V.. 0 NoD <br />27. (M TE OF DEATH 1""'-. o.y, Yr.) <br /> <br />- DATESlONEO /Mo.. ~y. Yr,1 <br /> <br /> <br /> <br />flli --.-~ ~~"" <br /> <br />2eb nlAE OF llEIITH <br /> <br /> <br />Ea <br />Il~ <br />~f <br /> <br />.. <br /> <br />214 PRONOUNCED DEAO 1"""'" <br /> <br />A. lA <br /> <br />.. <br /> <br />:lO.D WAS CONSENT GRANTED? <br />DYES r8J NO <br /> <br />Gordon <br /> <br />N. Custer Ave., Grand Island, NE 68803 <br />3at>, o..TE FILED 8Y REGISTRAR IMo.. D.I,. YI.' <br />JAN 1 2 2005 <br /> <br />I 32a RI:;,;ISTRAR <br /> <br />This is a <br />of Louise <br /> <br />true and accurate <br />Moreno. <br /> <br />copy of the <br /> <br />death certificate <br /> <br />Signed: <br />Sandra'Jean udd <br />Office Manager; <br /> <br /> <br />GENERAl NOTARY. Stale of Nebrulfl <br />SANDRA JEAN BUDDI <br />Comm. . June 23 - <br />