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<br />..
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL TH AND HUMAN SERVICES
<br />.. SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA ISTlCS/>ECTlP.-~- _-. _ IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,;;~_- -- ~ _ - -'~~--_ -.::._~_ "~,
<br />
<br />DA TE OF ISSUANCE -- ,c. ". ,_,- ~._
<br />FES 0 2 20 2 0 0 6 0 3 41 0 . - " STANLEYS. OOPER
<br />.06 - Ajs1_ ''AMlMAT~REGISTRAft
<br />LINCOLN, NEBRASKA HEALTH AN,O HUMIfit[--sERVi'eE$;;SY!STE~
<br />
<br />:,:. -~ .
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINAN~E?-~Ei~Li!'P~~O' 6
<br />_ ._fERTIFICATE O_~_PI:ATH----: , - -=>, - __
<br />
<br />20821
<br />
<br />DECEDENT'S-NAME (Flrsl,
<br />Maria
<br />
<br />Middle,
<br />Esther
<br />
<br />Le5l, Suffix)
<br />Martinez De Nunez
<br />
<br />2. SEX - -
<br />Female
<br />
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />January 31. 2006
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 81RTH Sa. AGE-Last Birlhd.y
<br />(Yr..) 46
<br />
<br />De Yurria. Mexi 0
<br />
<br />5b. UNDER 1 YEAR
<br />MOS. DAYS
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF 81RTH (Mo" Day, Yr.)
<br />
<br />November 3. 1959
<br />
<br />7. SOCIAL SECURITY NUM8ER
<br />639-48-7165
<br />
<br />B.. PLACE OF DEATH
<br />1iQSf'lIAL: ID Inpalient
<br />
<br />QlliEB: W Nursing Home/LTC 0 Hospice F.cilily
<br />
<br />FACiliTY-NAME (If not institution, give street and number)
<br />
<br />o ERIOutpatient
<br />
<br />U Decadent's Homa
<br />
<br />St. Francis Medical Center
<br />
<br />DlXJI\
<br />
<br />o Other (Specify)
<br />
<br />Be. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />
<br />68803
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />EUmY Hall
<br />
<br />
<br />9UIP CODE
<br />68801
<br />
<br />9g. INSIDE CITY LIMITS
<br />
<br />!Ii YES 0 NO
<br />
<br />1210 W. 7th St.
<br />
<br />10.. MARITAL STATUS AT TIME OF DEATH III Married 0 Never M.rried
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, l.sl, Suffix) If wile, give maiden name.
<br />
<br />o Married, but separated 0 Widowed Ll Divoroed 0 Unknown
<br />
<br />1 I. FATHER'S.NAME (First, Middle,
<br />David Martinez Gallardo
<br />
<br />Last,
<br />
<br />Suffix)
<br />
<br />Jose Nunez Castaneda
<br />12. MOTHER'S.NAME (First, Middle,
<br />Amalia Zurita
<br />
<br />Maiden SUrname)
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give datos 01 oervleell yes.
<br />
<br />
<br />Jose Nunez Castaneda
<br />
<br />- __~-J 16b L;2SE VO
<br />
<br />CITY / TOWN
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />Husband
<br />16e. DATE (MD., Day, Yr.)
<br />/-"i";- 2ooc;,
<br />
<br />STATE
<br />
<br />tip___,.
<br />15. METHOD OF DISPOSITION
<br />
<br />18l8u'ial o Don. lion
<br />
<br />o Cramallon 0 Entombment I 6d. CEM
<br />
<br />o Removal 0 Olher (SpecifY)
<br />__ Ozumbilla M~~!:cipio
<br />
<br />170. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, City Or Town, St.le)
<br />
<br />Apfel Funeral Horne 1123 West Second,
<br />
<br />Guanal'uato,
<br />De Yurria,AMex co
<br />
<br />.espl.alory errest, or venlricular IIbrlllation withoul Showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addlllonalllne. If necessary.
<br />IMMEDIATE CAUSE:
<br />
<br />(a) C....pl, ~._\..,..........,....s..
<br />DUE TO, OR ASIA CONSEQUENCE OF:
<br />
<br />eI<. -l.1v<o ""~ J
<br />
<br />~~<;.l C',,"C:>{
<br />
<br />onsel 10 dealh
<br />
<br />IMMEDIATE CAUSE (FInal
<br />disease or condRlon resulllng
<br />In death)
<br />
<br />~ t.\I'o-c""-'V\
<br />
<br />Onset 10 death
<br />
<br />Saquontlelly list conditiona, If (b)
<br />any, leading 10 the ceuse listed ----oi!1i'TO:OR AS A CONSEQUENCE OF:
<br />On line o.
<br />Entertho UNDERLYING CAUSE
<br />(dlsea.. or Injury Ihat Initiated (c)
<br />Iho ovonla re.ulllng In dealh)
<br />~
<br />
<br />onsello death
<br />
<br />I onsello death
<br />I
<br />~ I
<br />
<br />lB PART t"OTHER SIGNIFICANT CONDITIONS-CondltlDn~ contributing to tho de.it. but not resulting In ih~ und-;IYlng cause given In PARi-i-=ng WAS MWCAl EXAMINER - "
<br />OR CORONER CONTACTED?
<br />___ _ _ _ _ __ 0 YES _J( NO
<br />
<br />20. IF FEMALE: 21a~~NNER OF DEATH 21 b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />)i:f Net pregnant within past year .X! Natural 0 Hcmlclde DDriver/Operater "'/"0
<br />DYES p--N
<br />o Pregnant 01 lime of death 0 AccidenlD Pending Investigalion 0 Passenger
<br />
<br />o Not pregnant, but pregnent within 42 days of death 0 Suicide 0 Could not be delermlnad 0 Pedastri.n
<br />o Net pregnant, bul pregnent 43 days to 1 yeer before dealh 0 Olher (Speelly)
<br />
<br />o Unknown If pregnant within the pasl ya.r
<br />220 DATE OF INJURY (MO , Day, Yr) J 22b TIME OF INJ-UR:
<br />
<br />'22d.INJURY ATWORK-?J::2e DESCRI8E HOW INJURY OCCURRED
<br />U YES 0 NO
<br />------ - - ._-,.,.
<br />221. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAilABLE TO
<br />
<br />COMPLETE CAUSE OF DEATH?
<br />U YES 0 NO
<br />
<br />22c PLACE OF INJURY.At home, larm, street, I.ctory, Of lice building, conslrucllon elte, etc (SpeCifY)
<br />
<br />CITYrrOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />230. DATE OF DEATH (Mo" Day. Yr.)
<br />.___...____---.l::_ "3 \ ' 0 (..
<br />
<br />24a. DATE SIGNED (Mo" Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />~
<br />
<br />
<br />z
<br />"'0:(
<br />jQ
<br />ii~
<br />Q.::E:~
<br />e"-z
<br />8 ~o
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<br />r2!
<br />0:(
<br />
<br />23C. T~E,~ ~ATH-A
<br />tVq-l Pm
<br />
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<br />~~!l;!
<br />iii;~
<br />!~~~
<br />~~i:~
<br />Uw"
<br />"z=>
<br />.000
<br />~c:o
<br />o ~
<br />'-'0
<br />
<br />m
<br />
<br />24e. PRONOUNCED DEAD (Mo" Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />the time, date and place and due 10 the eause(s) stated. (Signature .nd Tille) "
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />,Not Applicable If 2_60 is NO 0 YES 0 NO
<br />
<br />NE. 68803
<br />
<br />26a. REGISTRAR'S SIGNATURE
<br />
<br />2Bb. DATE FILED BY REGISTRAR (MD., Day, Yr.)
<br />
<br />FEB 1 2006
<br />
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