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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA ~~RiA1CE3
<br />SYSTEM, IT CERTIFIES THE BELOW TD BE A TRUE COPY OF THE ORI©lN _.- ` w ~4D Dl~F.WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA~XI~S S,E'~~I~-~~l LS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - .~ _ -r`
<br />DATE OF ISSUANCE 2 0 0 9 0 710 4
<br />.... ~~~ ~R~R
<br />uEC ~ ~ zoaa A~~NT~~#,~~,R
<br />LINCOLN, NEBRASKA HEALTH AND~#Il/~~~ SY~`EM
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH ANA HUMAN SE'~fYl[~& F'12_ ~tA[+~~: ~D ~pOR7
<br />VITAL STATISTICS - - - - = - -_
<br />CERTIFICATE OF DEATH _ - -- - -_
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<br />t. pE EDENT -NAME FIRST MIppLE LA5Y ----
<br />2. SEX
<br />3, DATE OF DEATN lMpnrh, O.vy. Veaq
<br />Juana Guererro Puente Female Dec 6 2000
<br />1, CRY ANp STATE OF BIRTH /a not h USA., r7aaX9 awrMrY1 Sa, ADE • Leal Birdday UNDER 1 YEAR UNDER 1 DAY & DATE DF BIRTH /MonM. Dey. Veen
<br />8a1tx11o, Mexico IY~1
<br />91 Sb MoS. DAY5 Sc. HOURS1 MINE.
<br />Dec S 1908
<br />
<br />. SOCIAL SECURTIV NUMBER __
<br />B9. PIACE DF DEATH _, ._,
<br />
<br />507-56-0.139 HOSPITAL ~ klpalierq OTHER: ^ Nurairg Henn
<br />Sb. FACILITY-Name /Knot alsedrNpt!>^"e s>,ael and rxanberl ^ ER:OM ^ Residence
<br />Saint F'rax~ci,s Medical. Center ^ °OA ^ °p`e'/sPe~-ro'
<br />St:. CITY. T NOR LOCATION OF pFJ1TH bi. INSIDE CITV LIMITS tTe. COUNTY DF pFATH
<br />:.lr~l~a~n~id ...,.,,•, .,. Yea 3€ ~D Hall
<br />9a. RESIDENCE -STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /hrckrrq'ng lq7 Cane/ 9e INSIDE CITV LIMITS
<br />Nebraska Ha11 Grand Island 804 S. Curtis 6$803 Y~ ^X N~ ^
<br />10. RAOE - le.q., WtHBe. Black. American hdtan. 11. ANCESTRY le.q,. Nallan. Mexican, GermeA aecl 12. ^ MARRIED ®wIDOWED 13. NAME OF SPOUSE /a avip, give maiden name) -
<br />esJrsPe~dyl ISp.alyl NEVER DIVORGGD Manuel A. Puente
<br />His anic Mexican
<br />118. USUAL OCCUPATgN /ttlve kind M snrll oMre dlxLp mpsl 14b. KIND OF BUSINESS INDUSTRY t S. EDUCATION (Spepiy only hkTlleel grade compleledi
<br />oTaarkw2pNf,ewnlrmNedl ElenwMerywSecdldaryl0-121 Cdlegelt-1 or5~I
<br />Homemaker 5 0
<br />~15. FATHER -NAME FIR57 MIppLE LAST 17 MOTHER FIR5T MIDDLE MAIDEN SURNAME
<br />Celso Gue.x'erro Gabina -Guererro
<br />1& WA9 DECEASED EVER IN V.S. ARMED FORCES? et)a INFORMANT-NAME ~"~""~
<br />(Yes. rro. a txlk.l Id Yee. give wer std dates of servlceal
<br />,y+T9 / / __ / .. / Carmen Luna
<br />rra s..u+vIAN I MAAJNti AUUHCSS ISTREET OR R.F D. NO.. CITV OR TOWN, STATE. DPI
<br />649 Martin Ave. Grand Island. NE 68801
<br />3N~. lM4ALMER -SIGNATURE 8 LICENSE NO. -
<br />J
<br />~ 21 a MEfF1OD OF p$ppgRlpN 21p. OAYE 21C CEMETERY OR CREMATOFlV • NAME -
<br />~ .~,.
<br />..-
<br />.~
<br />- c. 1 2
<br />^X ataia ^Ramoval
<br />Dec 9, 2000
<br />WestlaWri Memorial Park
<br />12'~ I ERAL HOME -NAM 21d, CEMETERY OR CREMATORY LOCATION C17Y OR 7OWT1 STATE
<br />C ran Funeral Cha el ^~`"M"°n ^°aiai~' 3826 W. Stolle Park Rd. Grand Island NE
<br />22b. FUNERAL FIDNAE ADDRESS (STREET OR~R.F.D. NO.. CRY OR TOWN. STATE DPI "-"'
<br />3005 South Locust Street Grand Island NE 68801
<br />_
<br />23. IMMEDIATE CAII$~ (ENTER ONLY ONE CAUSE PER LW E FOR la(. 141. AND (CI) Inrervat between onset and oealn
<br />PART j ~
<br />1
<br />
<br />pVE TO, OR A CONSEQUENCE OF~. Irnarval behveen pleat anC deOM
<br />rot
<br />TO.OR AS A CDNSEpUENCE OF' I kaerval helwnen.o,atyl,gash-" -:
<br />.w.....~..~~...,,~..._..,.... -.
<br />........
<br />.....
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<br />PART OTHER $IGNRDANT CONDITIONS - CpWiliaw cprtNMSlnq to the deem but rrol releeed PART.NI IF FEMALE WAS THFJiE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAI.
<br />N. PREONANCV II4 THE PAST 3 MONTH5? L7(MMNER OR CORONER?
<br /> (A9BB 10-541. Yea No Yea No X Yoa Nb
<br />358. 25b. DATE OF INJURY /Mo. Day Yr./ 28c. HOUR OF INJURY 25d. DESCRIBE 11D1N INJURY OCCURREb
<br />AeNdeta ^ UAdeknn.red
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<br />CJ SulNde ~ Pending 25e. INJURY AT WORK 2&. p E C1F~ ~qY ;AI hp118, lazm, 9treel teclary
<br />dual
<br />AceCe
<br />l 25q, LOCATION STREET pFt R.F.b. Np, CITV OR TOWN STATE
<br />Hglaidlde InVeaage5pl Y~ ^ ~ ^ .
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<br /> ATH ( .
<br />. D,AY Yr./
<br />w. DATE t>F DE 258. DATE SIGNED /Ab.. Day Yr.l 2Bb, TIME OF DEATH
<br /> ry
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<br />~~ 27h. DATE SIGNED /Alq. Day. r.l
<br />~ 27c. TIME OF DEATH
<br />~r 25c. PRONOUNCED DEAD /Ma. Day Yr./ 28d. PRONOUNCED DEAD /Knurl
<br />
<br /> trd. T"~,
<br />~'~e detllh bcCUrliad at / Wne, dace and {~eu
<br />due to tna ~ Eg 258. On Iha heals d Bxaminatlon andrbr hvaalgalion. in my opinion dean, occurred at
<br /> -
<br />~1 1 shed
<br />s ~ r _
<br />J • the arM~ AMe eM P1xe end due Fo the cauae(s( ateted.
<br /> ra aAd THIS % !~~ Brld TMe
<br />23. 010 T OBACCO USE CONTRIBl1TE TO THE 3Da HA ORGAN OR TISSUE DONATION BE EN CONSIDERED? 30.b WAS CONSENT GRANTED?
<br /> ^ YES ~NO ^ UN ^ YES ~ 1~.~." ^ YE5 ~-
<br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONER"5 PHYSICAN OR COUNTY ATTORNL~/1 /Type a Prinq
<br />Dr. Gordon J. Hrx~icek 72 N. Cus a Ave. Grand Island N~ 68$03
<br />32a. REGISTRAq.
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<br />3L0~ VMI C FILCV pY Hktilpl W1H /aeu. uay, fr,/
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