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<br />~
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF TH~ NEBRASKA HEALTH 1WIl:-tt.4lMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINM.'SECOIiD '(js;,EILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL S~fjS!tLCS:ii6'er{~WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. J#=F ij~:--'~~c'-~~';:;: l~:'fj~~L
<br />
<br />
<br />:rUN Of 020'OsE ~~~J~:a:ER
<br />200610210 '-'ASSI6TANTSTAtE REG/S"RAR
<br />H$Lif!AND:l;!g4t~,NS~~/CES
<br />. " <"..,: ":~' .:.
<br />-=;c.~
<br />
<br />LINCOLN, NEBRASKA
<br />
<br />'\
<br />
<br />
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE;ANP-!i!j,!g1?cCJm::-
<br />CERTIFICATE OF DEATH . __c~
<br />
<br />
<br />I, DECEDENT'S-NAME (Flrsl,
<br />Romero
<br />
<br />Middle,
<br />
<br />Last,
<br />Martinez
<br />
<br />Suflix)
<br />
<br />2,SEX
<br />Male
<br />
<br />Mexico City, Mexico
<br />
<br />Sa, AGE.LaSI Blrlhday 5b, UNDER 1 YEAR
<br />(Yrs.) MOS. DAYS
<br />51
<br />
<br />5c, UNDER 1 DAY
<br />HOURS MINS,
<br />
<br />3, DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />l_11~"e 10, 2006
<br />
<br />6, DATE OF BIRTH (Mo" Day, Yr.)
<br />
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />
<br />February 11, 1955
<br />
<br />7, SOCIAL SECURITY NUMBER
<br />
<br />508-13-8216
<br />
<br />Sa, PLACE OF DEATH
<br />HOsPJ1&:
<br />
<br />o Inpatient
<br />
<br />QlJ1.fB; 0 Nursing Home/LTC 0 Hospice Facility
<br />
<br />FACILITY. NAME (It not Institution, glvo street and number)
<br />
<br />o ER/Outpallenl
<br />
<br />XI Decedent's Home
<br />
<br />4711 Gunbarrel PL
<br />
<br />01:0'1
<br />
<br />o Olher (Speclly)_._____
<br />
<br />80, CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island
<br />
<br />68801
<br />
<br />_ __t;~T~
<br />
<br />8d, COUNTY OF DEATH
<br />Hall
<br />
<br />10e, MARITAL STATUS AT TIME OF DEATH Ill1 Married 0 Novor Marriod lOb, NAME OF SPOUSE (First, Middle, Last, Sullix) If wlfo, give maiden name,
<br />
<br />
<br />91. ZIP CODE
<br />
<br />Nebraska
<br />9d, STREE;T AND NUMBER
<br />
<br />4711 Gunbarrel PL
<br />
<br />68801
<br />
<br />9g, INSIDE CITY LIMITS
<br />W YES U NO
<br />
<br />o Married, blll separated 0 Widowed 0 Divorced 0 Unknown
<br />
<br />Marie Brady
<br />
<br />Middle, LaSl,
<br />
<br />Homero
<br />
<br />Martinez
<br />
<br />Sufllx)
<br />Sr.
<br />
<br />12, MOTHER'S-NAME (First,
<br />Emma
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />13, EVER IN U,S, ARMED FORCES? Give dales of service II ye" 14a, INFORMANT-NAME
<br />No Marie de Martinez
<br />
<br />Luna
<br />14b. RELATIONSHIP TO DECEDENT
<br />
<br />15. METHOD OF DISPOSITION
<br />o Burial 0 Donation
<br />m Cremation 0 Enlombmenl
<br />o Removal 0 Other (Specify)
<br />
<br />16a. EMBALMER.SIGNATURE
<br />Not Embalmed
<br />
<br />16b, LICENSE NO,
<br />
<br />_ ______R :i;fe.___,
<br />1 Sc, DATE (Mo" Day, Yr, )
<br />June 10, 2006
<br />
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />
<br />CITY /TOWN
<br />
<br />STATE
<br />
<br />Central Nebraska Cremation Service
<br />
<br />Gibbon,
<br />
<br />17a, FUNERAL HOME NAME AND MAILING ADDRESS (Slreet, Cily orTown, State)
<br />
<br />PART l. Enter the c.hfll,n...o.Ll:!'te.n1s..-d!$e~ses, In/urIas, or campliC.QtlonS--II1e.t dl~eotly caused :he dsalh. 00 NOT entQ,r terminel evenls Si.Jch as cardla.c arrest,
<br />respiratory arrest, or ventricular fibrillation without showing tha etiology, DO NOT ABBREVIATE. Enter only one cause on a Une. Add additional lines If necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />on.ello dealh
<br />
<br />IMMEDIATE CAUSE (Ftnal
<br />disease or condition resulting
<br />In death)
<br />
<br />(a) C 4;tJ('CIl Or
<br />DUE TO, OR AS A CONSEOUENCE OF:
<br />
<br />/lMC/tt+5
<br />
<br />Q;V t __Y.i4d__
<br />
<br />on..t 10 daath
<br />
<br />Sequ.ntlally list conditione, If
<br />any, leading to the cause listed
<br />on IIno a,
<br />Enterthe UNDERLYING CAUSE
<br />(disease or injury that initiated
<br />tho ovent. ro.ulllngln death)
<br />lA':If
<br />
<br />(b)
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />onaat 10 death
<br />
<br />(c)
<br />
<br />..J ..
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />ons.1 to dealh
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contrlbullng to the dealh but nol re.ultlng In Ihe underlying cau,e given in PART I.
<br />
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTEO?
<br />
<br />W YES JU NO
<br />
<br />20, IF FEMALE:
<br />
<br />21a, MANNER OF DEATH
<br />ili Natural 0 Homicide
<br />
<br />o YES 00 NO
<br />
<br />o N~I pregnant within pasl year
<br />o Pregnant at time of death
<br />o Nol pregnanl, but pregnant within 42 days of death
<br />o Not pragnant, but pregnant 43 days to 1 year belore daath
<br />o Unknowll If pregnanl wllhln the past year
<br />
<br />o AccldonlU Pending Investlgallon
<br />
<br />21b. IF TRANSPORTATION INJURY
<br />o Driver/Operator
<br />
<br />o Passenger
<br />
<br />o Pedestrian
<br />
<br />o Other (Specily)
<br />
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />
<br />o Suicide U Could not be determined
<br />
<br />21d, WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES 0 NO
<br />
<br />22b, TIME OF INJURY 22c, PLACE; OF INJURY.At home, farm, streol, factory, offico building, construction silo, etc, (Specify)
<br />
<br />m-
<br />
<br />22d, INJURY AT WORK?
<br />
<br />o YES 0 NO
<br />
<br />22f, LOCATION OF INJURY - STREET & NUMBER, APT. NO,
<br />
<br />CITYITOWN
<br />
<br />STATE
<br />
<br />ZIP CODE
<br />
<br />240, DATE SIGNED (Mo" Day, Yr,)
<br />:o~ iH__________'n
<br />
<br />II >- ~ 24c, PRONOUNCED DEAD (Mo" Day, Yr,) 24d, TIME PRONOUNCED DEAD
<br />!f~~ m
<br />~~i':i5
<br />y knowledge death occurred at the time! date and place U w Z 24e. On the basis of examination and/or investigation, in my opinion death occurred al
<br />(JfL .. :z "0
<br />cau.~(.) t (td' (Slgnat Title~) T .0 0 Ihe time, date a"d place and due to Ihe cau.e(.) Slaled, (SlgnalUre and Title) T
<br />~:!i~
<br /><>0
<br />
<br />~,DIDTOBACCO USE CONTRIBUTETOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />o YES JI! NO 0 PROBABLY 0 UNKNOWN 0 YES 0{ NO
<br />27. NAME:TITLE AND ADOiiESS DFCEiifiFiiiii- (pj-iysiCIAN, COiiON'E'iioSPHYSICIAN OR COUNTY ATTORNEY) (Type or Prinl)
<br />
<br />David R. Colan M.D. 729 N. Custer AV Grand Island Nebraska 68803
<br />
<br />23a, DATE OF DEATH (Mo" Day, Yr,)
<br />__-!':l-ne 1 0~2_Q.96_
<br />
<br />24b, TIME OF DEATH
<br />
<br />m
<br />
<br />23c, TIME OF DEATH
<br />11:50
<br />
<br />Am
<br />
<br />26b, WAS CONSENT GRANTED?
<br />
<br />Not Applicabla if 26a I'__NO 0 YES Xl NO
<br />
<br />28a, REGISTRAR'S SIGNATURE
<br />
<br />
<br />28b, DATE FILED BY REGiSTRAR (Mo., Day, Yr.)
<br />
<br />JUN 1 6 2006
<br />E.,"-J.lld IT /I fi"
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