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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NE9RASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, lT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL A~~fl-pN FILE WITH
<br />THE NEBRASKA WEALTH AND HUMAN SERVICES SYSTEM, VITAL STAEaE~7C6~E~'TIC7I@;=1NH/CH lS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - - -
<br />DATE OF ISSUANCE _ v N -
<br />- fAI9tLLEY S.-COOPER
<br />MAY 2 5 2OO` =,aSS.sraNT STAF~9EGI$~J4AR
<br />LINCOLN, NEBRASKA 2 0 0 9 0 7 3 6 4 ~IEALTtI AAN~'fldlA~4/1E~R~ICEs
<br />STATE aFNEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FiNANOE AND 6UPPORT
<br />CERTIFICATE OF DEATH ' (~ ~ n ~ ~ ~ R
<br />
<br />- 1. DECEbENT'S•NAME First, Middle, Lest, Sulflx)
<br />( 2. SEX 3. DATE OF DE
<br />ATH (Mo., bay, Yr,)
<br /> ~_. _,... :. R a m n n a ~.._,_,.~1LZ71LA-11-_--_ y--~ ice. __ _ Female M a 18 2 0 0 5
<br /> A. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 56. UNDER 1 YEAR 5c. UNDER 1 bqY 8. PATE OF BIRTH (Mo., Dey, Yr.)
<br /> (Vre.) 55 Mos. DAYS HOURS MINE.
<br />1 Tan. 27
<br />1950
<br />J
<br /> Trejos, Jalisco Mexico ,
<br /> 7~SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />~ 5 0 8 - 31-_ 9 6 5 4 )iOSPITAL: U Inpatient bTMER ~ Nuraing HomeA.TC ^ Hospice Facility
<br />---
<br />~ BbAME (II not Inelltutlon, give street and number)
<br />~ ~ ERIOutpetlant ^ Decedent's Home
<br /> St. Francis Skilled Care
<br /> ^ pps, ^Other(Specity) _..
<br />-
<br />~ = 5c. CITV OR TOWN OF bEATH (Include ZIp Code) 8d. COUN7V OF bEATH
<br /> _ Grand Island _68803
<br />Hall
<br />~
<br /> 9e. RESIDENCE•STATE _
<br />9b. COUNTY __
<br />9a CITY OR TOWN ~~
<br />-- Nebraska Hall
<br />m Grand Island
<br /> 9d.5TREETAND NUMBER 9e. APT. NO 9f. ZIP CObE 9g. INSIDE CITY LIMITS
<br /> 42,2 West 10th St. 68801 ~I YES ^ NO
<br /> 1oa. MARITAL STATUS AT TIME OF DEATH ~Manled p Never Married 106. NAME OF SPOUSE (FIrs6 Middle, Last, suttlx) It wife, glue maiden name. T •
<br /> Cl Merrled, but separated ^ Widowed ^ Divorced ^ Unknown M e l q u i a d e z G u z m a n
<br />_ 11. FATHER'S-NAME (First, Middle, Last, Sulflx) 12. MOTHER'S•NAME (FIrs6 Middle, Malden Surname)
<br />~ ' Jase Refu io Veliz :
<br />~~~nte~
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<br /> ~. EVER IN U.S. ARMED FORCES? Glve dates of service if yes. .._.. __
<br />t4a. INFORMANT-NAME ~ -
<br />....-
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<br />146. RELATIONSHIP TO DECEbENT
<br /> (Yea, no, dr dnk.) O-...
<br />._ M P S n 11 7~ (~ P
<br />z
<br />Husband
<br />_ 15. METHOD OF bISPOSITION ...... _._.___
<br />iBe~BALMER•SIGNAT i8b. LICENSE N0. 16c. DATE (Mo., Day, Yr. )
<br />~~
<br />- Q Burial ^ Donation ( (~ r ~~~~
<br />13 2 8 M a 21 2 0 0 5
<br /> 5[1Crematlon ^Entombmenl 18d.CEMET Y,CREMATpRYOR THERLOCATION CITY/TOWN STATE
<br />~ L]Removal ^bmer(speolry) Central Nebraska Cremation Service Gibbon, Nebraska
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<br />t7a. FUNERAL H 17b. Zlp Code
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<br />ocust St. Grand Island NE 68$01
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<br />18. PART I. Enter the chain of avems--diseases, injuries, yr cvmpllcations--that dlrectty caused the death. DO NOT enter lermtnal events such as cardiac arrest, APPROXIMATE INTERVAL
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<br /> respiratory arrest, w ventricular IIbrlltatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional Imes a necessary. I
<br /> IMMEDIATE CAUSE: 4 i ansetwdeath
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<br />IMMEDIATE CAUSE(Flnal
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<br /> dlseaseorconddlvnreeulgng DUE T0, OR AS A CONSEQUENCE OF. ~ I onset to death
<br /> In death)
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<br />' Sequen8ally Ilet condltlona, II (b) I
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<br />- eny,leadingtathecaueelleted pUETO,ORASACDNSEQUENCEOF: ,. I onset to death
<br /> on Ilne a.
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<br />Enter the UNDERLYING CAUSE
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<br />' (dleeaaeorln)urythatlnltleted (o) I
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<br />- _._._._.. _......-.. _.. _....- -- ..............-_. I .~..._....
<br />theeventereeultinglndeath) pUETO,ORA5ACONSEOUENCEOF~ I onset todealh
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<br /> 18. PART 11.OTHER SIGNIFICANT CONDITIONS-Canditlons contributing to the deelh but net resulling In the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br />saAll
<br /> ^ VES U NO
<br /> 20.~IFFEMALE: 2ta.MANNEROFDEATH 21 b: IFTRANSPORTATtONINJURV 21c.WA5ANAUTOPSYPERFORMEb?
<br />~'
<br />-_ ~~'Naturel ^ Homicide ^ DdvedOperatw
<br />~lotpregnentwlthlnpastyear
<br /> ^YES ~NO
<br />~] Pregnant at time of death ^ Accldent^ Pending Invastlgatlon ^ Passenger , ~y
<br />~
<br />~ ^ Not pregnant, but pregnant wlihln 42 days of death G Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />CI Sulclde ^ Could net be determined
<br /> [)Other (Speclly)
<br />^ Nat pregnant, but pregnant 43 days to 1 year before death COMPLETE CAUSE OF DEATH?
<br /> ^ Unknown K pregnant wlihln the past year OYES ^ NU
<br />
<br />i.. , .,,22e.0ATE OF IN,tIRY_(Mv-, (`ay, Vr.J. 27_b,IIA!E of INJI:PY... 2$~P~ n_ rE C1F~J.u[}XAShamc,farotai[.e~ ~rlr~ollk,:,,6u!lding,aona'~ucJo:~rlte,~::.{Spaolty)_
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<br />- 22d.INJURYATWORK? 22e.DE5CRIBEHOWINJURY000URRED
<br /> [,J YE5 ^ NO
<br /> 221, LOCATION OFINJURY -STREET & NUMBER, APT. N0. CITV/LOWN STATE ZIP CODE
<br />
<br />~'~ 23a. DATE OF DEATH (Mo., bay, Yr.) ,.. 24e. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH
<br />May 18
<br />2005
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<br />23b.DAT tONEb Mo.,Day,Yr.) 23c.TIMEOFDEATH ~~ 24c.pRONOUNCEDDEAD(Mo.,Day,Yr.) 24d.71MEPRONOUNCEDpEAP
<br />°? EaZ 5 ~~~ 2:45 P. m tea'' m
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<br />~ 23d. To the best of my knowledge, death occurred at the time, date and place w ~ ~ 24e. On the basis of examinallonend/or Invesligatlon, In my opinion death vccuned al
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<br />cause(s) state
<br />, (Signature and Tllle) - .
<br />p ~ the time, date and place and due to the cause(s) stated. (Signature and Title)
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<br />r: 25. DID70BA000 USE CONTRIBUTET07HE bEATH7 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br /> _ ^ YES "NO ^ PROBABLY ^ UNKNOWN ©YES NO Not Applicable 1128a to NO ^YES ^ NO
<br /> 27. NAME,TITLE A b AbDRESSOF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY TtORNEV) (Type or PrInQ mm
<br />'.' William Landis M.D. 2444 W._Faid]„ey Ave. ,Grand Island NE 68803
<br /> 2Sa. REGISTRAR'S SIGNATURE 28b. DATE FILED BV REGISTRAR (Mo., bay, Yr.)
<br /> ~• MAY 2 3 2005
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