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<br />~
<br />
<br />
<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AN,DH(JMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIG//VAL; ItECQittt:t>>lBLE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIS ----~Wl:J'_CH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. -",,~,.,~~
<br />
<br />
<br />DATAurtiU62005" "i'''~' . -:~~~'~C~~
<br />'. ..;ASSlsTA"'istifIF~ii/STRA8
<br />liEiA:tir)vm fltJM~:N"$EgVicj!;
<br />, "" ~i}~ , ~"'=-~ .:.-~r=~'=- ~~~E7~:., ,.~~~. - ~---
<br />~_ .,\"',;;'..~_..;~.~_-,,~-=-7'"~C:~:,' _
<br />. ~~~_~~: -_~~~;~~:,.~~?~~:,~1 ~f:~;j:~
<br />
<br />S1. A..",E. OF NEBRASKA - D. EPARTMENT OF HE. A. LTH AND HUMAN S. ERVICES FINANCEA"-N.'-USUF>F'.SR-T- 2-C .0 8 7 2 2
<br />__ _ ___ CERTIFIC_ATE OF D!;~TH . _'", . 0 ~ __ __ __
<br />1. DECEDENT'S.NAME (First, Middle, Last, Suffix) 2. SEX 3. DATE OF DEATH (Mo.. Day, Yr.)
<br />Andrew (NMI) Vasquez Male August 3,2005
<br />4 CITY ~ND STATE OR TERRITORY, OR FOREIGN COUNTF1Y~;aAGE-Last Birthday 5b. UNDER 1 YEAR 5c UNDER 1 DAY 6. DATE OF 61RTH (Mo., Day, Yr.)
<br />Guanajuato, Mexico I (Yrs) 93 MOS. DAYS HOURS MINS. Oct. 10, 1911
<br />
<br />7. ~OCIAL SECURITY NUM6ER '---I' Ba. PLAC~OF. DEATH
<br />508- 0 1- 6 2 7 8 .__~__ -tl8..?--~..:.- . cc_':'.I~.:'~;,:nl -c_... omfB: 0 Nursing Home/LTC 0 Hospice Facility
<br />o ER/O;;at'~rJt ',,,.>.' ';"~tti;~;~';~"~'Home'~ "'~"" ~ i\."
<br />
<br />416 W. 6 t h St. 0 !Xl'. OOlher(SpecllyL
<br />
<br />LINCOLN, NI=sRASKA
<br />
<br />200901858
<br />
<br />,", :
<br />
<br />~...:.....;:.-
<br />
<br />\,j
<br />
<br />Be. CITY OR TOWN OF DEATH (Inciud. Zip Cod.)
<br />Grand Island
<br />
<br />68801
<br />
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />9a. RESIDENCE-STATE
<br />Nebraska
<br />
<br />~J 9b. COUNTY Hall
<br />
<br />
<br />91. ZIP CODE ....~..9...IN... SloiiCITY LIMITS
<br />68801 __L~ YES 0 NO
<br />
<br />9d. STREET AND NUMBER
<br />416 W. 6th St,
<br />
<br />fOa. MARITAL STATUS ATTIME OF DEATH CXMarri.d U N.ver Married
<br />
<br />o Dlvorc.d 0 Unknown
<br />
<br />lOb. NAME OF SPOUSE (Firsl, Mlddl., Last, Suffix) If wlf., give mald.n nama.
<br />Eva Aguilar
<br />
<br />11. FATHER'S-NAME (First, Mlddl.,
<br />_~.11 d r e w Vas qu e z
<br />
<br />Lasl,
<br />
<br />Su1llx)
<br />
<br />12. MOTHER'S-NAME (First,
<br />
<br />Catalina
<br />
<br />Middle, Malden Sumeme)
<br />
<br />_~_()p~3:__
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />(Yes, no, or unk.)
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dates ot service iI y.s. 14a.INFORMANT-NAME
<br />No
<br />
<br />Eva Vasquez
<br />
<br />15. METHOD OF DISPOSITION
<br />o Buri.1 0 Don.ilon
<br />
<br />'6a'V~E~;SIGNATUR
<br />
<br />'-"'..2L
<br />Kl Cr.mailon 0 Entombm.nt 16d. CEME-TERY, CREMATORY OR OTHER LOCATION C. CITY !TOWN
<br />o Removal [J Other (Specify) C e n t r a 1 Neb r ask a C rem a t ion S e r v ice G i b bon ,
<br />
<br />
<br />16b. LICENSE NO.
<br />
<br />1071
<br />
<br />16c. DATE (Mo.. D.y. Yr.)
<br />August 8, 2005
<br />
<br />STATE
<br />Nebraska
<br />
<br />- --". -
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Sire ai, Clly or Town, Sial')
<br />Home,2929 S. Locust St.
<br />
<br />
<br />
<br />Grand Island, NE
<br />
<br />
<br />18. PART I. Enter thellh.aln.Ql.~..dls.a'e., InJurl.., or compllcatlons"1hat dlr.ctly c.used the death. DO NOT .nler lermine'.vent. .uch eo c.rdlac ,"esl,
<br />respiratory arrest, or ventrlcula.r librillation wlthou!showing the etiology. 00 NOT ABBREVIATE. Enter only one cause on a tine. Add additional lines If necessary.
<br />
<br />APPROXIMATE INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />I
<br />I
<br />
<br />I onsellO dealh
<br />I
<br />I
<br />I UAO'I...o
<br />IAnset to death
<br />I
<br />I
<br />I
<br />I ons.t 10 daalh
<br />I
<br />I
<br />I
<br />I onsello death
<br />,
<br />I
<br />
<br />IMMEDIATE CAUSE (Final
<br />dl..... or condition re,ulllng
<br />In death)
<br />
<br />(a) r/--/"?>""
<br />DUE TO, OR AS A CONSEQUENCE OF
<br />
<br />Sequenlli!lIy list conditions) If
<br />anylll!i!ldln9 to the cause listed
<br />on iln. a.
<br />Ent.r 'h. UNOERLYING CAUSE
<br />(dl..a.. or Injury thet Inltl.t.d
<br />the .v.nt. r..ultlng In d.eth)
<br />LAST
<br />
<br />(b) ~/ ?,::A/
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />(d)
<br />
<br />PART iI. OTHER SIGNIFICANT CONDITIONS.Condlllons contributing to the d.alh bul not resulling in the und.rlylng C.use given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />
<br />o YES ./I( NO
<br />
<br />/
<br />~j/..l /.L~>i,
<br />20. IF FEMALE/'
<br />o Not pr.gnsnl wllhln pesl year
<br />o Pr.gnanlalllm. 01 d..th
<br />o Nol pr.gnanl, bUl pregnent within 42 day. ot death
<br />o Nol pregnanl, bul pregnanl43 days 10 1 yeer before dealh
<br />o Unknown iI pregnant within the pest year
<br />
<br />21a. MA~ER OF DEATH
<br />~elural 0 Homicide
<br />
<br />o AccldenlO Pending Inv.silg.llon
<br />
<br />21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PpFORMED?
<br />CJ Driver/Operator J
<br />cafES JP NO
<br />
<br />o P....ng.r
<br />o p.deslrl.n
<br />o o'lhe, (Specify)
<br />
<br />[J Sulcld. 0 Could nol b. d.l.rmlned
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILA6LE TO
<br />COMPLETE CAUS~ OF~H7
<br />_ _ ._~~__ /.~_YE~ .~___~_
<br />22c. PLACE OF INJURY-AI home, larm, ,Ir.el, laclory, office building, conslrucllon .11., .tc. (Speclly)
<br />
<br />22a. DATE OF INJURY (Mo.. Day, Yr.)
<br />
<br />22b. TIME OF INJURY
<br />
<br />m
<br />
<br />22d.INJURY AT WORK?
<br />
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />
<br />DYES 0 NO
<br />
<br />221. LOCATION OF INJURY. STREET & NUMBER, APT. NO.
<br />
<br />crTYITOWN
<br />
<br />SOOE
<br />
<br />ZIPCOOE
<br />
<br />23a. DATE OF DEATH (Mo.. D.y, Yr.)
<br />August 3, 2005
<br />
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Au ust 5,2005
<br />
<br />24a. DATE SIGNED (Mo.. Day, Yr.)
<br />
<br />Nb. TIME OF DEATH
<br />
<br />23c. TIME OF DEATH
<br />4:10 P.m
<br />
<br />...:i i:;
<br />.c!;jZ
<br />H~
<br />n~~
<br />1l~5
<br />..;~ {d a:: 0
<br />8li
<br />
<br />m
<br />
<br />Nc. PRONOUNCED DEAD (Mo.. Day, Yr.) Nd. TIME PRONOUNCED DEAD
<br />m
<br />
<br />24e. On Ih. basi. of .x.mln.llon .nd/or Inve.tlgatlon, In my opinion death occurr.d al
<br />Ih. tlm., dal. and plac. and due 10 the cause(.) slal.d. (SlgnelUr. and Till. ) T
<br />
<br />25. DIDT06ACCO USE 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />DYES ~O 0 PROBABLY 0 UNKNOWN 0 YES ~
<br />27. NAME, TlTLr AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSiCIAN OR COUNTY ATTORNEY) (Typeor Print)
<br />Jane McDonald, M.D. 800 Alpha St., Grand Island,
<br />
<br />2Ba. REGISTRAR'S SIGNATURE
<br />
<br />
<br />NOI Appli~~~!_~I.~~~ Is NO
<br />
<br />Nebraska
<br />
<br />68803
<br />
<br />
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />AUG - 8 2005
<br />
<br />-..--.
<br />
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