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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RATSED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH APJD HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FDR VI7"AL 17ECORDS.
<br />DATE OF ISSUANCE ~„ ~-'..( "~
<br />~~/~
<br />05/14/2009 ~ O O 9 O 5 8 O O STANLEY S Gt'7fW7PER
<br />,4$$~$~AI~~~TAT~ REGI$TJ~AR
<br />LINCOLN, NEBRASKA ~E'RAJ~,~L!f.OF HEALTH f1Np
<br />Mf,!l~~N SERVICES
<br />STATE DF NEBRASKA - DEPARTMENT DF HEALTH AND HUMAN SEt~VICE~ ' ~'' r ~ ° O9 01 O31
<br />CERTIFICATE OF DEATM ~`
<br />d
<br /> 1. DECEDENT'S-NAME (Fist, Middle, Oast, Suttlx) 2. SF.I( ~ ' ,;!! { i y 3.~DA'(B~F' TH (Mo., Day, Yr.)
<br /> Har Albino Eoriatti Male' a ,~ 0~9 '
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF 81RTH 5a. AGE • Last Birthday b. UNDER 1 YEAR 5c. UNDER:1 DA : QATE 01= BIRTH (Mo., Day, YrJ
<br />,
<br /> (Yrsd MOS. DAYS HOURS MINS:.
<br /> Des Moines, Ipwa 83 August 15; 1925
<br /> 7. $pCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 484-18-5572 WOSPITAL ®Inpatlent OTHER ^ Nursing HomelL7C ^ Hospice Facility
<br /> eb. FAGILITY•NAME (If not Instltutlpn, glue street and number) ^ ER/Oukpatient ^ Decedent's Home
<br /> _
<br />F•
<br />V $8~11t FranC15 MedICBI Center ^ DOA ^ Other (Specify)
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<br />tX Bc. CITY OR TOWN OF DEATW (Include Zip Code) 8d. COUNTY OF DEATH
<br />5 Grand Island 68803 Hall
<br />J 9a. RESIDENCE•$TATE 9b. COUNTY 9C. CITY OR TOWN
<br />z
<br />Nebraska
<br />Hall
<br />Grand Island
<br />~ 9d. STREET AND NUMBER 9. APT. NO. tN. ZIP CODE 9g. INSIDE CITY LIMITS
<br />T 213 West 21st Street 68801 ®Yts ^ No
<br />a 10a. MARITAL STATUS AT TIME OF DEATH ®Marcled ^ Never Married 10b. NAME OF SPOUSE (First, Mlddla, Last, Suttlx) If wife, glue maiden name
<br /> ^ Married, but separated ^ Widowed ^ Divorced ^ Unknown Nancy Camerpn West
<br /> 11. FATHER'S-NAME (First, Mlddla, Last, Suttlx) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Frank Eoriatti Mary Sandra
<br />fl•
<br />E t3. EVER IN U.S. ARMED FORCES? Give dates of service NYes. 14a. INFORMANT•NAME 74b. RELATIONSHIP TO DECEDENT
<br />$ (Yes, No, or unk.) Yes 08113/1943-09/22/1945 NanC Camerpn Eoriatti Spouse
<br />1~ 15. METHOD OF DISPOSITION 18a. EMBALMER•SIGNATURE 18b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />~
<br />~ ®Burlal ^ pOnatlOn
<br />Daniel D Naranjo
<br />1071
<br />May 13
<br />2009
<br /> ,
<br /> ^ Cremation ^ Entombment
<br /> 18d. CEMETERY, CREMATORY OR OTHER LOCATION GITY /TOWN STATE
<br /> ^ Removal ^ Other (Specify)
<br /> Glendale Cemetery Des Moines Ipwa
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 176. Zip Coda
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> A E F EATH ee instructions and exam les
<br /> 18. PART I. Enter the rJtaln pf evauta--dlaeaaaa, InJurles, or compllca[lona~that dlrotYy wuaed the dodth. p0 NO7 enter ternllnal events such ae cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratory aneaL or ventricular abrillatlon without ahowlnp the etiology. DO NOT ABBREVIATE. Enter only one Cause on a Iina. AAA adAitlonal pees If necessary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a) Acute Respiratory Failure 12 Hours
<br /> dioeaoe or condipon resuRinq
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Se4uentlally list conaltione, If b) Cardiovascular Collapse E 12 Hours
<br /> any, leaning to the Cauca Iisled
<br /> on Iina a.
<br />DUE 70, OR A$ A CONSEQUENCE OF: ; onset to death
<br /> Emer the UNDERLYING CAUSE C)
<br /> Idlsease or InJury that lnaiated
<br /> the evema resuninp in death) DUE TO, OR AS A CONSEQUENGE pF: onset to death
<br /> LAST d)
<br /> 18. PART I1. pTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART 1. 19, WAS MEDICAL EXAMINER
<br /> OR CORONER CpNTACTEDT
<br />~ ^ YE$ ®NO
<br />w 20. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not pnpnant wlthln pant year ®Natural ©Homiclde ^ Ddvar/pperator
<br />
<br />U
<br />^ Pregnant at time of death
<br />^ Accident ©Pendlnp Inveatlgatlon
<br />^ Passenger ^ yE3 ® Np
<br />
<br />~' ^ Not pregnant, but pregnant wlthln 42 days of death
<br />^ Suicide ^ Could not ba datnmined ^ Pedestrian 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
<br />^ Npt pregnant, but pregnant 4, days to 1 year Wforo death
<br />©Other (Specly) TO COMPLETE CAUSE OF DEATH?
<br />«G ^ Unknown If pregnant wehin the past year
<br />^ YES ^ NO
<br />n
<br />E 22a. bA7E OF INJURY (MO., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, ?arm, atreat, factory, office building, construction site, etc. (Specify)
<br />0
<br />p
<br /> 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCGURRED
<br />0
<br />~
<br />^ YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET & NUMBER, APT.NO. CITY(rOWN STATE ZIP CODE
<br />
<br />_ 23a. DATE OF DEATH (Mq., Day, Yr.)
<br />.,- ------ --- -- .-.~._. _.~_-__-.
<br />- 24a, DATE SIGNED (Mq., Day, Yr.)
<br />-- _ . - ~
<br />: - --- 246. TIME DF DEATH
<br /> ~~ May 8;
<br />Zb09 ~; .
<br /> ~ 23b. DATE SIGNED (Mo., Day, Yr.) 2Sc. TIME pF DEATH ~ ~' ~ r
<br />m 24c, PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCEp pF.Ap
<br /> a = Ma 12, 2009 02:45 PM rl a z
<br />e
<br /> O 8d. To the beat of my knpwledge, dsdth paurrod it the time, date antl place
<br />~ _
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<br />r+ ~ ~ p
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<br />2~• On the baala of eadminatlon and/or InVestigatlon, in my opmlon death occurred at
<br /> and due tq the rauaa(a) orated. (8lgnaturo end Title)
<br />o ~
<br />'' ~ ~
<br />n
<br />~ the lima, date and place and due to the wuaa(a) afatad. (Blgnaturo and Tkla)
<br /> Jennifer L. Brown, MD $ ;
<br /> 25. pip TpBACCO USE CONTRIBUTE TO THE DEATH? 28a. HAS pRGAN pR TISSUE DONATION BEEN CONSIDERED? 286. WAS CONSENT GRANTEp~
<br /> ^ YE$ ®NO ^ PRpSAeLY ^ UNKNOWN ^ YES ®Np Not Applicable if 28a Is NO ^ YES ^ Np
<br /> R 1 I IA R N (ype or Print)
<br /> Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 2gb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> May 12, 2009
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