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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 CERT1FIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECQRD ON FILE WITH <br />THE NEBRASKA HEAL TH AND HUMAN SERVICES SYSTEM, VITAL STAn$1!G-S'~r~ .WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,.::~':-:.,j".c_'-' 7=j~ <br /> <br />DATE OF ISSUANCE ~A.r;:':y1ff!tR <br />7/7/2004 2006087 85 ~S8lsT~f,o$J."~l1e(jfJfflAft <br />LINCOLN, NEBRASKA HEAL TH ANl1tWMA~IflIIl:E~ sySTEM <br /> <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND IIlIMAN'$iv.l~EiFilWtCE~S.i:JpPORT <br />VITALSTATISTICS,o'.c,-,...,: 0=-'..:"04 0 7 0 6 4 <br />CERTIFICATE OF DEATH . '. u_ <br /> <br />1. DECEDENT - NAME <br /> <br />FIRST <br /> <br />MIDO~E <br /> <br />LAST <br /> <br />2. SEX <br /> <br />3. DATE OF DEATH IMoo,". Day. Y..,) <br /> <br />Jesse <br /> <br />James <br /> <br />Munoz <br />Sa. AGE. Last 8irthdav UNDER 1 YEAR <br />{Yrs.1 Sb. MOS. DAYS <br />66 <br /> <br />Male <br /> <br />June 24, 2004 <br />6. OATE OF BIRTH (Moo,". Day. Yoa,) <br /> <br />4. CITYANDSTATEOF81RTH lffoo/iIlU.SAno""'CCW1trtl <br /> <br />UNDER 1 DAY <br />5e. HOURS' MINS. <br /> <br />October 5, 1937 <br /> <br />Lexington, NE <br />7. SOCIA~ SECURTIY NUMBER <br /> <br />8a. PLACE OF DEATH <br /> <br />8b. FACll,.rrV - Name <br /> <br />(If not InstiftJticm. give street and nl)mb9f) <br /> <br />HOSP!T!,:: ~ <br /> <br />o <br />o <br /> <br />Inpatient OTHER: 0 Nursing Home <br />EFI Outpatient 0 Residence <br />OOA 0 Other (SJJeC//VI <br /> <br />507-40-9743 <br /> <br />St. Elizabeth's Regional Medical Center <br />8e. CITY. TOWN OR ~OCATION OF DEATH <br /> <br />11, ANCEST~Y 18.g.. Italie,l't 8xican. German, elel <br />ISpeclly1 American <br /> <br /> <br /> <br />o <br /> <br />8d. INSIDE CITY ~IMITS <br /> <br />Lincoln <br /> <br />i' 9.. RESIDENCE - STATE <br /> <br />Nebraska <br />~ 10. RACE - (e.g., White. Black. American Indian. <br /> <br />etc.IISP.<11y1 Hispanic <br /> <br /> <br />(Including ZIp Coo.) <br /> <br />ge. INSIDE CITY ~IMITS <br /> <br />Grand Island <br /> <br />Ye. @ NO 0 <br />13. NAME OF SPOUSE. IIf wife. giV8 maiden name) <br /> <br />Helen Vasquez <br /> <br />14a. USUAL OCCUPATION fGi\l8 kind 01 WDfk dont~ dvdflg most <br />01 WOri(lng life. even if rSllted} <br />Supervisor <br /> <br />16. FATHER - NAME FIRST MIDDLE <br /> <br />Factory <br />~AST <br /> <br />15. EDUCATION (SpeCIfy only highest grade completedl <br />Elementary or Si,,!,dary 10-12) Collog. 11-4015'1 <br /> <br />Genaro <br /> <br />Munoz, Sr. <br /> <br /> <br />Filiberta <br /> <br />Godinez <br /> <br />17. MOTHER <br /> <br />MIDD~E <br /> <br />MAIDEN SURNAME <br /> <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />(Yes. r'lo. or unk.) !If yes, gIve war and dales of servicesl <br />Yes Vietnam 8/10/1961- 8/9/1963 Helen Mlllloz <br /> <br />19b. INFORMANT MAI~ING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP} <br /> <br />no W. 14th Street, Grand Island, NE 68801 <br />20. EMBALMER _ SIGNATURE & LICENSE NO. 21a. METHOD OF OISPOSITIDN 21b. DATE <br />~lli \'2:1<0 0 Burial 0 Removal 6-29-04 <br /> <br />21 C. CEMETERY OR CREMATORY NAME <br /> <br />Westlawn Memorial Park Crematory <br /> <br />22.. FUNERAL <br /> <br /> <br />21d. CEMETERY OR CREMATORY lOCATION <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />All Faiths Funeral Home, LLC <br /> <br />~ Creflliiltion 0 Donallol'l <br /> <br />Grand Island, NE <br /> <br />22~. FUNERA~ HOME ADDRESS <br /> <br />{STREoT OR R.F.O. NO.. CITY OR TOWN. STATE. liP} <br /> <br />2929 South Locust Street, Grand Island, NE 68801 <br />23. IMMEDIATE CAUSE IENTER ONLY ONE CAUSE PER LINE FOR /al.lb). ANO(cll <br />PART <br />I la\ CARDIC ARREST <br />DUE TO, OR AS A CONSEQUENCE OF' <br /> <br />0 Accident 0 Undetermined <br />;0 SuiCide 0 pending 260. INJURY AT WOR~ <br />:0 Homicide Investigation "esO NoD <br /> <br />M <br />261. ~~~SU~~I~~~~~.V (:~~,. farm, street. factory 26g. LOCAilON <br /> <br /> <br />Interval D$tW88n Qnse~ and dealll <br /> <br />{b} RESPIRATORY FAILURE <br />DUE TO. OR AS A CONSEOUENCE OF, <br /> <br />PART orHER SIGNIFICAN"T CONDITIONS - Conditions contributing 10 tne dealh but not related <br />II <br /> <br />1<1 USUAL INTERSTITIAL PNEUMONITIS <br /> <br />268. <br /> <br />coronary artery disease <br /> <br />28b. DATE OF INJURY (MO.. Day. Yr.) 26e. HOUR OF INJURY <br /> <br />STREET OR R.F.D. NO. <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />27.. DATE OF DEATH (Mo.. Day. Yr) <br /> <br />28.. DATE SIGNED (Mo.. Day. VO <br /> <br />28b. TIME OF DEATH <br /> <br /> <br />M <br /> <br />$~ <br />]l~ <br />l..~ :: <br />eo.~ <br />.!i~ <br />o ~ <br />~" <br /> <br />27c. TIME OF DEATH <br /> <br />280. PRONOUNCED DEAD {Mo.. Day, Y'-I <br /> <br />28<1. PRONOUNCED DEAO (Houri <br /> <br />M <br /> <br />28a. On the basis of Bxamina.ion and/or Investigation, in my opinion death occurted at <br />the lime. date a.nd place and dl,le to the cause(ti) stated. <br /> <br />!Si nature and Titlel ... <br />30.. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED> <br /> <br />o YES Q(NO <br /> <br />3O.b WAS CONSENT GRANTED? <br />o YES ~NO <br /> <br />31. NAME AND ADDRESS OF CERTIFIER IPHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (TyPB or PriOI) <br />'EliEn Miller, M.D. 1500 S. 48th Street, Suite 605, Lincoln, NE 68506 <br />32.. REGISTRAR <br /> <br /> <br />32b. DATE FI~ED 8Y JtJi\rA~ ('g' 0"2004- <br />