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<br />/. <br />, . <br />;' '')"K <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEAL rn AND tiJMAN SERVICES <br />SYSTEM, "~RTlFIES THE BELOW TO BE A TRUE COpy OF THE ORlGIAJfit. ~.:w ON FII!fWlTH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VlTAL_~ ~, ~/S <br />"",'LEGAL DEPOSITORY FOR IIITAL RECORDS. ~~~~" -~~ ~,,': <br />~ ~ - .,:'-' ~ ~ \ <br /> <br />DATE OF ISSUANCE 200809933' l~~ -- ~" ~_.~ __ , .1,1 ' <br />MAY 1 0 1999 ~ ~~s$i;~~ ~L::l:;=! <br />LINCOLN, NEBRASKA HEALRii~ HUMAN~~D\'S <br />STATE OF NEBRASKA. DEPARTMENT OF HEALTH ~ ~VlC:~~C~ S RT <br />VITALSTAns'lttls ....._":.',,;:'-'"':'"< ."i: <br />CERTIFICATE OF fjma.~~-o,~-'_-=;= <br />'. DECEDENT. NAME FIRST MIDDLE LAST J. DATE OF DEATH (Month. o.y. Y..rl <br /> <br />Victor <br /> <br />NMN <br /> <br /> <br />Male April 27, 1999 <br />UNDER I YEAR UNDER 1 DAY 6. D"'TE OF BIRTH (MoIl"'.o.y. Y..r) <br />5D. MOS DAYS 50. HOURS' MINS <br /> <br /> <br />12, 1915 <br /> <br />4. CITV AND STATE OF BIRTH Iff 110/ in u.s.A.. """'" countryl <br />San Luis Potosi, Mexico <br /> <br />:: 7. SOCI"'L SECURTIV NuMBER <br /> <br />. <br />.J <br />.~ 8b F "'CILITV . Name <br /> <br />:J <br />.1 <br />80. CITv. TOWN OR LOCATION OF DEATH <br /> <br />(N t'tOr lfI$tItutiOrr, gi.. itrMt 1M numl>>r) <br /> <br />HO~~~T AL: 0 Inp81ienl <br />o ER Oulpalltnl <br />000... <br /> <br />OTHE~; <br /> <br />0 Nursinv Home <br />00 ReSidence <br />0 Cltner (s.p.c.!y' <br /> <br />508-12-7376 <br /> <br />1223 E. <br /> <br />7th St. <br /> <br /> <br />Nebraska <br /> <br />Hall <br /> <br /> <br />(1M/vIJ/nQ Zip C_I <br /> <br />90. INSIDE CITY liMITS - <br /> <br />ed. INSIDE CITY liMITS <br /> <br />Grand Island <br /> <br />g.. RESIDENCE. ST",TE <br /> <br />.,eIISooe,1y1 Hi <br />spanic <br /> <br />"0 USU"'L OCCUP...TlON 10,"" kindolworl< -. during most <br />II of working life, even if retir(l(ll <br />Maintainence <br />.. <br />!i '6. FATHER. N"'ME FII1ST <br /> <br />l Wenceslao NMN <br />.. , 8 WAS DECEASED EVER IN U.S "'RME') FORCES? <br />.. {Yes. no. c~ wnk.1 I (I' yes. give V{'.r arw:l dale~ Or 'ServiCC'. J <br />No ------- <br /> <br />11. ANCESTRV l8.Q" hallan. Mell:iC:lln. Oerman. etcl <br />IS(IOO'Iy) <br />Mexican <br /> <br />7th St. 68801 v.. Q No Q <br />13. N"'ME OF SPOUSE Iff WI". g;"" ~n "'''''1 <br /> <br />Cam <br /> <br /> <br />11 MOTHER <br /> <br />Julia A uilar <br />15. EDUC"'TION l$pocllyooly "1QIlOIl1l'''''" 0_1 <br />EIO...nt.'YOI See""".,., 10.121 Collogo ".4 O' 5-1 <br />5th Grade <br />MIDDLE MAIDEN SURN"'ME <br /> <br />MIDDLE <br /> <br />Manuela <br /> <br />NMN <br /> <br />Martinez <br /> <br />19D. INFO~MANT <br /> <br />......'L1NG ...i>DRESS <br /> <br />__. Julia Campos - Wife <br />ISTREET OR R.F.D. NO. CITY OR TOWK ST", TE. llP\ <br /> <br />1223 E. <br /> <br /> <br />68801 <br /> <br />21 &. ~ETHOO or: OISPl,.SITlO~'; <br /> <br />i21:;;. 30, ~::-::::::-~l~=-- <br /> <br />2'0 CEMETERV OR CREMATORV LOCATION CITy OR TOW~ ST...TE <br /> <br />[] Butil!l.l [J Flemoval <br />-- <br /> <br />o CremalJ(Vl 0 OcnallOl'1 <br />22D. FuNERAL HOME "'D[)R~ IS' REET OR RF.D. NO.. CI7V OR TOWN. STATE. liP) <br /> <br />Grand Island. Nebraska <br /> <br />601 N. Webh Road, Grand Island. Ne. 68803-4050 <br /> <br /> <br />. ~aiberw;;;;;s~t1 ~~- <br /> <br />(ENTER ONL V ONE CAUSE PER LINE FOR 1.1. IDI. "'ND lell <br /> <br />I <br />I <br />r Inle~\tal between cnSe1 and oeaW, <br />I <br />I <br />I <br />25. W"'S C"'SE REFERRED TO MEDIC...L <br />EX",MINER OR CORONER? <br /> <br />o Acclclel"1l 0 <br />o SUlctde 0 Pencing <br />o HomICide InlleslIga1lon <br /> <br /> <br />2:Jb, DATE OF INJURY (MtJ.. Day. Yr.) 26c HOUR OF INJURY <br /> <br />26. <br /> <br />26e INJURY AT WORt( <br />Yes 0 No 0 <br /> <br />2611. LOC'" TION <br /> <br />STREET OR R.F.D. NO <br /> <br />CITV OR TOWN <br /> <br />STATE: <br /> <br />21. <br /> <br />28a DATE SIGNED (Mo.. 08.., 'If} <br /> <br />281> TIME OF DE...TH <br /> <br />-... ~~ <br />~IL <br />.. ~"' ~ <br />- <:J riS <br />- 11 " <br />.~ ~:i; <br />J <br /> <br />April 27 I <br /> <br />1999 <br /> <br />z >- <br />EP <br />l~h <br />~h <br />u 0 <br /> <br />M <br /> <br />28<;. PRONOUNCED DE"'D IMo.. o.Y. Yt.1 <br /> <br />26<1. PRONOUNCED DEAD (H,,,'" <br /> <br />M <br /> <br />M <br /> <br />a'7d To lhe betl 01 my knowledg4!l. dea <br />~l.IseIS) slated. <br /> <br />_ 15, nallJre and T~ <br />zg. DID TOSACCO USE CONTR THE DE"'TH' <br /> <br />Y 0 yES NO ~NKNOWN X' <br /> <br />3'. NAME "'ND ADDRESS OF CERTIFIER (PHVSlCI...N. CORONERS PHVSICIAN OR COUNTY ATTORNEYI ITYfJO 01 P,;nr) <br />'"---- - - <br /> <br />28e. On the basi, of t!llcaminabon IlM'Ot" jnynligaOOfl" in '"Y' opiniQt1 dealn occurred al <br />rile Ii~. date and place and due to the ClllJUflli) "'-ted. <br /> <br />JO.b WAS CONSENT GR"'NTED' <br />.y' 0 YES .ttf NO <br /> <br />X Jane <br />32. REGISTR...R <br /> <br /> <br />Island Ne 68803 <br />32b. D'" TE FILED SV REGISTR...R <br />MAY <br /> <br />(Mo.. D.y. Yr.' <br /> <br />6 1999 <br /> <br />/ <br />