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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE DEPARTMENT OF HEALTH, <br />IT CERTIFIES THE BELOW TO SEA TRUE COPY OF AN ORIGINAL RECORD ON FILE W ?H r"E siATE <br />DEPAJIMMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL D,OPOSIMA* FOR <br />VITAL RECORDS. <br />DATE OF ISSUANCE ' <br />STANDS; O"PER <br />LINCOLN, MAR NEBRASKA ASKA 2 0 0 510 9 8 4 NEBRASKA DERA t �T O HEALLTH <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FWAN k _ <br />C�iIND S[?�IeQRT <br />VITAL STATISTICS - O 3 02305 <br />CERTIFICATE OF DEATH <br />1. DECEDENT - NAMF FIRST MIDDLE LAST <br />7 Sfx <br />3. DATE OF DEATH lMpmn Day year) <br />Tirso NMI Borrego <br />Male <br />March 2, 2003 <br />4. CITY AND STATE OF BIRTH !n ml v U.S.A. name counfryl <br />$a. AGE -Last Birthday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />S. DATE OF BIRTH /Month. pay Yearl <br />5b.MOS DAYS <br />Sc HOURS MINIS <br />Durango, Mexico <br />frr5.) 72 <br />June 6, 1930 <br />J 7. SOCIAL SECURTIY NUMBER Be . PLACE OF DEATH <br />508- 21-w5502 HOSPITAL. � Inpatient OTHER: ❑ Nursing Home <br />8b. FACILITY - Name 01 nol mshfufion, give slr9er and numper/ ❑ ER Outpatient ❑ Residence <br />is Good Samaritan Hospital ❑ OOA ❑ Other (Specify, <br />17 Accident F] Undetermined <br />8C. CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS Be. COUNTY OF DEATH <br />Kearney Yp5 ® No ❑ Buffalo <br />9a. RESIDENCE - STATE <br />9b COUNTY <br />90. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER /Including Xlt Codel <br />TY LIMITS <br />Nebraska <br />Buffalo <br />Kearney <br />707 West 29th 68845 <br />=Y.S�"� <br />No ❑ <br />E Whito. Black. American Indian. <br />11-, (a g.. Italian. Mexican. German, etcl <br />12. MARRIED ❑WIDOWED <br />13 NAME tlF SPOUSE !7I wile. gwe ma,een name) <br />-((eeg., <br />IGEINI <br />1�_ <br />JAgNpC@�ESTRY <br />t118�anic <br />NEVER DIVORCED <br />MARRIED <br />Louisa Berumen <br />._.. <br />- UAL OCCUPATION /Give kimo/ work done during most <br />14b. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed( <br />Elementary or Secondary (0 12) College I1 -4 or 5 I <br />3 <br />Il wo kr li /e. a nil eti edl <br />ro2tuc� ion Worker <br />Turkey Processing Plant <br />27b DATE SIGNED /Mo. Day. Yr.) <br />27C. TIME OF DEATH <br />j16 FATHER -NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />i Leon Borrego <br />Elena Barxagan <br />12:14 F Mme_° <br />_... <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a INFORMANT - NAME <br />lYHOs ,�o. or unk.l fit yes. give war and dales of services( <br />1yVN <br />Mr. Primitive Borrego <br />19b. INFORMANT MAILING ADDRESS (STREET OR R D NO.. CITY OR TOWN. STATE. ZIP) <br />707 West 29th Street, Kearney, NE 68845 <br />20. EMBALMER • SIGNATURE. 8 LICENSE NO <br />?.1a METHOD OF DISPOSITION <br />21b. DATE I 21c CEMETERY GR CRFMATORY NAME <br />' "rte 1313 <br />IN Burial ❑ Removal <br />Mar 10, 2003 Villa Ocampo Cemetery <br />22a. FUNERAL HOME • NAME <br />21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Horner- Lieske- Horner Mortuary <br />❑ Cremation ❑ Donation <br />Durango Mexico <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />P.O. Box 777 „ Kearney, NE 68848 <br />-1 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR 18I. to). ANU (c)) Interval oefiveen onset am oeam <br />- PART <br />I I <br />(al / <br />DUE , OR AS A CO EOUENCE O i Interval between onset and dealt) <br />/4"S <br />DULFTO, OTAS A CONSEQUENCE OF: I Interval between onset am evaln <br />/1 <br />(�I Ur r-r <br />I <br />OT R SIGNIFICAN ONDITIONS - Conditi9ft contrib ng .the death but not related PART <br />III IF FEMALE WAS THERE A <br />24 AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />(Ages 10 -54) Yes No 7 1 <br />Yes No j{ <br />Yes 7 No <br />26a. IF I <br />26b. DATE OF INJURY /Mo.. Day. Yc1 <br />260. HOUR OF INJURY <br />26d. DESCRIBE. HOW IN..JRY OCCURRED <br />17 Accident F] Undetermined <br />M <br />Suicide � Pending <br />260. INJURY AT WORK <br />26f. PkAC� OF. INJURY - pt hop, farm. Street. factory <br />269. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />EjHomiride Inyoshgal'on <br />Yes No <br />❑ ❑ <br />o c0 mldmg. etc. ISpecify) <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />28a DATE SIGNED fMo.. Day Yr.1 <br />28b. TIME OF DEATH <br />Ir= <br />March 2, 2003 <br />s -° <br />M <br />Y <br />27b DATE SIGNED /Mo. Day. Yr.) <br />27C. TIME OF DEATH <br />28c. PRONOUNCED DEAD lMO.. Day. Ycl <br />28d. PRONOUNCED DEAD (Hour) <br />gP° <br />March 3, 2003 <br />12:14 F Mme_° <br />M <br />u <br />my knowledge. death cur d at e. dale and place and due to the <br />28e On the basis of examination and or Investigation, in my opinion death occurred at <br />_ <br />~ r <br />? 3 <br />° s <br />. <br />=., <br />the time. date and place and due to the causelsl stated. <br />l j <br />(Si Hamra and Title mm _ <br />a DID TOBACCO USE CONTRIBUTE DEATH? <br />30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.4 WAS CONSENT GRANTED? <br />❑ YES ❑ NO UNKNOWN <br />❑ YES NO <br />❑ YES NO <br />T <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( ITyper o(Pont) <br />Dr. S.L. Smith M.D. P.O. Box 550, Kearney, NE 68848 -0550 <br />_..-.. <br />32a REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo. Day. Yr.) <br />J11A A <br />MAR 0 4 2003 <br />/ / -- U _ <br />