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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AC@..MtIM.~VICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGIN>4~~~f.WIP~' r!:!iH ~.
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA~'$\SFC:FION,. :"U: IS
<br />
<br />:::~:::;RY FOR VITAL RECORD& . ;>; ~ ..~'i~~\
<br />200808358>t=:, ....."- ..'w~~,
<br />L~~~O:~~~:BRASKA 200 80 7 2 5 2 ~~A;;'-Afj)H!f"Mfl~=t13'::
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<br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH AND HUMAN se:~':(S"S ~;.5'S~~'~ )~? ~:-::'<08 00480
<br />CERTIFICATE OF DEATH ,,' '&'j' .........> 1:J'U'.,:s
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<br /> "j,,," '; .
<br /> 1. DECEDENT'S.NAME (First, Middle, Last. Suffix) 2. SEX~;0~\:\..~' 3.tlJ.Te.Qt"OEATH (Mo., Day, Yr.)
<br /> Frank Ramirez Rivera Sr Male '..-", .~ 16;2008 '
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTI4 Sa. AGE. Last Birthday b. UNDER 1 YEAR 5c. UNDER 1 OAY 6. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. I DAYS HOURS I MINS.
<br /> McAlester, Oklahoma 89 April 15, 1919
<br /> 7. SOCIAL SECURITY NUMBER 6a. PLACE OF DEATH
<br /> 508-30-9038 ~ IZIlnpatlent OTHER 0 Nursing HomelL TC o Hospice Facility
<br /> 6b. FACILITY.NAME (If not Institution, give atreet and number) o ERlOutpatlent o Decedent's Home
<br />g;: .' ---
<br />0 Mary Lanning Memorial Hospital ODOA o Other (Specify)
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<br />W Bc. CITY OR TOWN OF DEATH (Include Zip Code) IBd. COUNTY OF DEATH
<br />IX
<br />C Hastings 68901 Adams
<br />..J 9a. RESIDENCEoSTATE 19b. COUNTY 19C. CITY OR TOWN
<br />:!
<br />w Nebraska Hall Grand Island
<br />% reo APT. NO.
<br />::l 9d. STREET AND NUMBER 191. ZIP CODE 199. INSIDE CITY LIMITS
<br />1I. 621 N. Pine St. 68801 l2il YES 0 NO
<br />>.
<br />.c 10a. MARITAL STATUS AT TIME OF DEATH 1&1 Married 0 Never Married 110b. NAME OF SPOUSE (First, Suffix) If wife, give maiden name
<br />al Middle, Last,
<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 />"C
<br />tl Joe Rivera Pauline Ramirez
<br />Ci 13, EVER IN U.S, ARMED FORCES? Give dates of service If Yes. I 14a, INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />8 (Yes, No, or Unk.) Yes 08/18/1941-12/11/1945 Frank Rivera Jr Son
<br />II 15. METHOD OF DISPOSITION 16a. EMBALMER.SIGNATURE 116b. LICENSE NO. 16c. DATE (Mo.. Day, Yr.)
<br />0 1&1 Burial o Donation Kevin Wood 1325 April 21,2008
<br />I-
<br /> o Cremation 0 Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE
<br /> o Removal o Othsr (Specify) Grand Island City Cemetery Grand Island Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 117b. Zip Code
<br /> Livingston-Sondermann Funeral Home, 601 N. Webb Road, Grand Island, Nebraska 68803
<br /> GAUSE OF ee instructions and exam Dies)
<br /> 18. PART I. Enter the chain of eve~t.. -dlnah., Injuriel, or compllcatlon.-that directly CauMd the delllth. DO NOT enter t8nnlnllllllllvem. such a. cardiac 8rrt.t. APPROXIMATE INTERVAL
<br /> relpiratory arre.... or ventricular fibrillation without .nowlng the e11010gy. DO NOT ABBREVIATE. Enter only Ontl cau," on a 11M. Add addttlonalllna.lf n8C8a&111ry.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAuSE (Flnll a) RENAL FAILURE 2 WEEKS
<br /> diMaH or condition resulting
<br /> Indoath) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> SeQuontlllly list condltlono, If b)
<br /> any. loadln9 to tho cauto lIoted
<br /> on line III.
<br /> DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter tho UNDERLYING CAUSE c)
<br /> (dlseillse or Injury that Initiated
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)
<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 />IX o YES 1&1 NO
<br />W ~O. IF FEMALE: 21a. MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br />ii:
<br />fi o Not pregmmt within pa5t y..r 00 Natural o Homicide o Drlvlllr/Operator o YES 1&1 NO
<br />W o Pregnant at tlltMl of death o Accldont o Pondlng Invostlgltlon o PaSHnge,
<br />U
<br />~ o Not pregnant. but pl'8gnant within 42 days of death o Sulcldo o Could nol bo dstonnlnOd o Podostrlln 21d, WERE AUTOPSY FINDINGS AVAILABLE
<br />o Not pregnant, but pregnant 43 days to 1 year before death o OIho, (Specify) TO COMPLETE CAUSE OF DEATH?
<br />~ o unknown If pregnlnt within I.. plst yoa' o YES o NO
<br />Cl. 22a. DATE OF INJURY (Mo., Day, Yr.) 122b' TIME OF INJURY I 22c, PLACE OF INJURY-At home, farm, street, factory, Office building, construction site, etc, (Specify)
<br />E
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<br />II 22d. INJURY AT WORK? r2e. DESCRIBE HOW INJURY OCCURRED
<br />r= o YES ONO
<br /> 221. LOCATION OF INJURY. STREET & NUMBER, APT.NO. CITYITOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo.. Day, Yr.) '!:1:; 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> :a April 16, 2008 ._..~,._,.,,~~,-~
<br /> I"' Q ~ --
<br /> I~>- 23b. DATE SIGNED (Mo., Day, Yr.) I 23c. TIME OF DEATH li~~ 24c, PRONOUNCED DEAD (Mo.. Day, Yr,) 24d. TIME PRONOUNCED DEAD
<br /> ia.~ April 17. 2008 08:50 AM
<br /> ~o ~3d. To Iho best of myknowlldgo, dOllh occu'red Illho 111110, dllO Ind pllco 8~~~ 24e. On the ba,l, of examination and/or Investigation, In my opinion death occurred iilt
<br /> ! ~ and duo to tho caU"(I) otelod. (5lgnalure and TIIII) !~~ tho tlmo, dato and ploco and dul to Iho cauto(O) stated. (5Ignll.re Ind Tille)
<br /> {!. !! Justin Wen burg, MD {!.~~
<br /> '"
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 126a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? II 26b. WAS CONSENT GRANTED?
<br /> o YES o NO o PROBABLY 1&1 UNKNOWN 1&1 YES 0 NO Not Applicable If 26a Is NO 0 YES 1&1 NO
<br /> 27. NAME, TITLE AND ADDRE:!:! UF L:ERTIFI . ,. , (I ype or I"nntJ
<br /> Justin Wenburg, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68901
<br /> 2Ba. REGISTRAR'S SIGNATURELLrc.. ,. - Aw r 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> -u - April 23, 2008
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