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<br />STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH A~M~VICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGIN4~e'iJ.FJCj;P!I.,iI~fH ~.
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA1'IiT!f{:s'$FC'FIOti. ~ ,'Z':.lS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,-1 ':: t:) "':;V7~ 5t~<>.,
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<br />DATE OF ISSUANCE p.f ~
<br />"" ~ . ,'" " ,.... (..,~~ of.
<br />04/24/20.08 '.'.,~. .",,": '.,.... ~. E.~.W~ "CQ..~... /$..0.. .PEIfJ." .' "'....::
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<br />LINCOLN, NEBRASKA 2 0 0 8 07 25 2 HT;:!~N;HI1M~NS~R~~!J .?
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SI;R~'S.~f'.s lFi l.,~)\-:>~ ):/~~::';}'08 00480
<br />CERTIFICATE OF DEATH .., 'U';. ...........'. \,';;\').,.,.; .
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<br /> 1. DECEDENT'S-NAME (First. Middle. Last. Suffix) 2. SEX (,'l,. IJI.' h.~~EATH(r.lO.. Dsy. Yr.)
<br /> Frank Ramirez Rivera Sr Male ,. \. '>", . "" ~n 16. 2008..:
<br /> 4. CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH Sa. AGE. Lnt Birthday b. UNDER 1 YEAR 5c. UNDER '1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. I DAYS HOURS I. MINS.
<br /> McAlester, Oklahoma 89 April 15, 1919
<br /> 1. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 508.30-9038 HOSPITAL IZIlnpatlent OTHER 0 Nursing HomelL TC o Hospice Facility
<br /> 8b. FACILrrv.NAME (If not Institution, give street end number) o ERlOutpatlent o Decedent's Home
<br />II:
<br />0 Mary Lanning Memorial Hospital ODOA o other (Specify)
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<br />(.)
<br />W 8c. CITY OR TOWN OF DEATH (Include Zip Code) 18d. COUNTY OF DEATH
<br />a:
<br />is Hastings 68901 Adams
<br />.J 9a. RESIDENCE.sTATE 19b. COUNTY 19C. CITY OR TOWN
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<br />w Nebraska Hall Grand Island
<br />z \ge. APT. NO.
<br />:=! 9d. STREET AND NUMBER T 9f. ZIP CODE \99. INSIDE CITY LIMITS
<br />ll. 621 N. Pine St. 68801 l2SIYES 0 NO
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<br />~ 10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married 110b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />o Married, but separated 0 Widowed 0 Divorced 0 Unknown Mary Rebecca Aldana
<br />~ 11. FATHER'S.NAME (First, Middle, Last, Suffix) 112. MOTHER'S.NAME (First, Middle, Malden Surname)
<br />~ Joe Rivera Pauline Ramirez
<br />Q. 13. EVER IN U.S. ARMED FORCES? Give dates Of service If Yes. 114a.INFORMANT.NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />8 (Yes,No,orUnk.)Yes 08/18/1941-12/11/1945 Frank Rivera Jr Son
<br />.! 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 116b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />0 o Burial o Donation Kevin Wood 1325 April 21, 2008
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<br /> o Cremation 0 Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br /> o Removal o other (Specify) Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) \l1b. Zip Code
<br /> Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br /> CAUSE OF DEATH (See Instructions arid examDles\
<br /> 18. PART I. Enter ttU) chain of eventS. -cll$8i1seB, InjurieS. or complh:::lilltlo~'..that directly caused the d..h. DO NOT enter wnnlnale".nts such .. cardiac arrest. APPROXIMATE
<br /> INTERVAL
<br /> ,..pi....tory arre,,-, or ventricular fibrillation without l!!Ihowlng tl:18 etiolOgy. DO NOT ABBREVIATE. Enter only one caUH 0... a line. Add IiIIddltlonalllne.lf nee.nary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUlIE (Flnol a) RENAL FAILURE 2 WEEKS
<br /> dlse3S8 or condition r8sunlng
<br /> In doOlh) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Sequontlally 1101 condition.. If b)
<br /> ony. loodlne to tho cauoellotod
<br /> on line 8. DUE TO, OR AS A CONSEQUENCE OF:
<br /> onset to death
<br /> Enter tho UNDE"~ YING CAUSE C)
<br /> (CIlMase or Injury that Initiated
<br /> tho OIIonto rosultlng In doath) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> ~AST d)
<br /> 0
<br /> 18. PART II. OTHER SIGNIFICANT CONDITIONS.condltlons contributing to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> GASTROINTESTINAL BLEEDING OR CORONER CONTACTED?
<br />a: DYES o NO
<br />w O. IF FEMALE: 21a. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />ii:
<br />~ o Not pregnant within past year IX) Natural o Homlcld' o D~vorfOperotor DYES o NO
<br />w o Pregnant at tUne of death o Accldont o Pending InveBl:lgatlon o pa,..nger
<br />(.)
<br />:s- O Not proenont. but proenant wllhln 42 day. of doath o Sulcldo o Could not be detennln.d o p.dool~an 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />o Not pregnant, but pregnant 43 dlillY' to 1 year before death o othor (Specify) TO COMPLETE CAUSE OF DEATH?
<br />~ o Unknown If prognont wnhln tho paBl yoor DYES o NO
<br />Q. 22a. DATE OF INJURY (Mo., Day, Yr.) \22b. TIME OF INJURY I 22c. PLACE OF INJURY.At home. farm, street, factory, office building, construction site, etc. (Specify)
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<br />.! 22d. INJURY AT WORK? r2e. DESCRIBE HOW INJURY OCCURRED
<br />{!. DYES ONO
<br /> 22f. LOCATION OF INJURY. STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br /> 21~. DATE OF DEATH (Mo., Day, Yr.) :;;1':: 241. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> .:~ -April 16, 2008--.... -~ ..-- .. n --.---.-..
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<br /> ..~ 23b. DATE SIGNED (Mo., Day. Yr.) \ 23c. TIME OF DEATH 1~1~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> iI~ April 17 2008 08:50 AM
<br /> i~~ 3d. To the beat of my'knowledge, death occurred at the time. date and place S;~O 248. On the basis of examination and/or Investigation, In my opinion death occurred IiIIt
<br /> J '8 J Z
<br /> and due to the cause(.) elated. (Signature and Thle) ,,~~ the time, date and pllillce and due to the caUN(S) stated. (Signature and Title)
<br /> ~ S Justin Wenburg, MD I- '"
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<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 1268. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? I 26b. WAS CONSENT GRANTED?
<br /> DYES o NO o PROBABLY 0 UNKNOWN o YES 0 NO Not Applicable If 26a Is NO 0 YES o NO
<br /> 27. NAME, TITLE AND ADORE TIFIER (PHYSICIAN. CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or prlnlf
<br /> Justin Wenburg, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68901
<br /> 28a. REGISTRAR'S SIGNATUREiLr~ "-(J A~ r;. -- '. I 28b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.)
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<br /> I II April 23, 2008
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