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<br />STATE OF NEBRASKA
<br />~ WF'1'EN THIS CpPY CARR/ES THE RAISED SEAL OF THE NEBRASKA H6,~k ~ ANl?~$ER1~IC~~S
<br />"'~'~ SY$'rEM, /T CERTIF/ES THE BEL pW Tp BE A TRUE COPY OF THE QR~Gi CQL~ ~_ _ 1~TF~' ':
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL !I,~1~~/~JC~_71V~A~31w~C/S!'
<br />THE LEGAL DEPOSITORY FpR VITAL RECORDS. '~.w-~- ~
<br />DATE pF ISSUANCE
<br />AuG 2 8 200fi 2oioo4o2~ r ~ ~ ~~~~
<br />~~~ ~~~
<br />L/NCOLN, NEBRASKA FIB . '~/,'AMbVA~E,~ .;.
<br />~!~+ _ -
<br />STATE r7F NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICt~S F1NAAiG¢>ti,NF~ S,~ ~y
<br />CERTItcICATE OF DEATM - ~w~ ~ ~.:7
<br />1. DECEDENT'S-NAME (First, Mlddle, Last, 5uftix) 2. SEX 3. pATE OP DEATH (Mo., pay,Yr.)
<br />Venda Jean WeIDh-Lopez Female August 15, 2006
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE-Last Birthday 5b. UNDER 1 YEAR 5C. UNnER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MO5. DAYS HOURS MINS.
<br />Grand Island, Nebraska 24 September 10, 1981
<br />7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
<br />507-15-7933 H~~PJ_TAI.: ^ Inpatient O1HER ^ Nursing Home/LTC ^ Hospice Fedllty
<br />8b. FACILITY-NAME (II not Inslltutlon, give street and number) ^ ER/OU~ellent $I becetlent'BHoma
<br />1421 West North Front Street C t3DA ^ oEter s ecl - -
<br />1 P 41-_~.~._.
<br />6c. CITY OR TOWN OF bEATH (Include Zlp Code) Bd. COUNTY OF DEATH
<br />Grand Island 68801 ball
<br />9a. RESIpENCE-STATE 9b. COUNTY 9c. CITY OR TDWN
<br />Nebraska Hall Grand Island
<br />Bd. S7REE7ANDNUMBER Be. APT. NO 9f. ZIP CODE 9g.INSlp6 CITY LIMITS
<br />1421 West North Front Street 68801 [z7 YES ^ Na
<br />t0a. MARITAL STATUS AT TIME OF DEATH fj(t Mri~frled Ll Never Marned 10b. NAME OP SPOUSE (First, Mlddle, Last, Sulllx) If wife, give maiden name,
<br />^Marned, butseparaletl ^ Widowed q nrvorced ^ Unknown
<br /> Juan Carlos Lopez Cereceres
<br />11, FATHER'S•NAME (First, Mlddle, Lasl, Sufnx) t2. MOTHER'S•NAME (First, Mlddle, Malden Surname)
<br />Lar Welch Desma Willett
<br />13. EVER IN U.5. ARMEp FORCES? plve dales of service tfyes. 14a.INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />(Yea, no,orunk.) ND Juan Carlos Lopez Cereceres Husband
<br />15, METHOD pF DISPOSITION 16a.SMBALMER-SIGNATURE 16b. UGEN5E N0, 18c. DATE (Mo., pay, Yr. )
<br />~ Burial ^ ponadon l ~ August 21, 2006
<br />^Cremetlon C]Entombment 16d.CEMETERY,CflEMATORYOROTHERLOCATION CITY/TOWN STATE
<br />^Removal C~Dmer(Specny)
<br /> Sacred Heart Cemetery Greeley Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADpflESS (Street, Clty orTown, Stale) 17b. Zlp Cade
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />- ---- 68801
<br />A SE OF pEpTH (See instructions and examples) - _ ____ -. _
<br />18. PART I. Enter the chain olevents--diseases, InJudes, or compllcatlons••thal directly caused the death. p0 NOT enter terminal events such as caNlac arrest, AF'PROXtMA7E INTEFlVAL
<br />I
<br />respiratory arrest, orventrlCUlar Ilbdllallon without showing the etlology. DO NOT ABBREVIATE, Enter only one cause on a Ilne. Add addltlonal ones If necessary. I
<br />IMMEDIATE CAUSE: I cnsellodeath
<br />~ I
<br />IMMEDIATE CAUSE(Fhal la) 1
<br />dksaaarcandabnreatllrg DUETU,OR ACONSEQUENCEOF; I onseltodsath
<br />h death)
<br />I
<br />Sequentlalty Ilat conditions, h (b) I
<br />I
<br />arty, had[ng to the cause listed
<br />OUE TO, OR A5 A CONSEQUENCE OF: I onset to tlealh
<br />on Ilns a.
<br />I
<br />FJNar Eta UNDERLYING CAUSE
<br />(disease orln)urythathitlekd (c) I
<br />msevsntsrssuEinghdeeEt) pUE70,ORA5ACONSEQUENCEOF: I nneeltodealh
<br />l~r
<br />I
<br />(d) I
<br />18. PART IL OTHER SIGNIFICANT CONDiTIbNs•Conditions contributing to the death but not resulting In the underlying cause given m PART I. 19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> YES CJ NO
<br />20.IPPEMALE: 21a.MANNEROFDEATH 21b.IFTRANSPORTATIONINJURY 21 c. WASANAUTOPSYPERFORMED7
<br />^ Not pregnantwllhln pastyear Q Natural ^ Homlade ^ bdver/Operator
<br />~ YES ^ NO
<br />^ Pregnant at time of death ^ Accident^ Pending Investlgatlon
<br />^ Passenger
<br />
<br />^ Notpregnant,btltpragnanlWithln42daysofdeam
<br />f~SUtdde ^COUldndtbatle1911Tllnad ^ Pedestrian
<br />21tl.WEREAUTOPSYFINDINGSAVAILABLETO
<br />^ Not pregnant, but pregnant 43 days to 1 yearbelore deem ^ Omer (Spedfy) COMPLETE CAUSE OF DEATHS
<br />Unknownilpregnantwlthlnthepaetyear ~,-_,_ ~ ~ YES ^ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, factory, office building, conaliuctlon site, etc. (SpsCily)
<br />8/15/2005 unknown m residence
<br />22tl.INJURYATWOP,K? 2?e. DESCRIBE HOW INJURY OCCURRFp
<br />U YES ~NO Hanging
<br />221, LOCATION OF INJURY • STREET & NUMBER, APT. N0. CITY/TOWN STATE ZIP CODE
<br />1421 West North ):'root Stree-~' Grand Island, NE
<br />68801
<br /> __
<br />23a.OATE OF DEATH (Mo., Day, Yc) s 24a. GAiE 51GNEU (Mo., Day,Yr.) f 24b.TIME OF UEA7H
<br />~~ ~~a 8/25/2006 unknown m
<br />S '
<br />yr 236. DATE SIGNED(Mo.,pey,Yr.) 23C.TIMEOFDEATH ~i~ 24c.PRONOUNCEDDEAp(Mtl„pay,Yr.) 24d.TIMEPRONDUNCEDDFApjr
<br />OUXld
<br />Ea= m Ewaz 8/15/2006 8:50 Pm
<br />8~0
<br />~ ,~
<br />23d, To the best of my knowledge, death occurred at ma time, date and place $ z ~ ° 24a. On me bases of exeminaq andlor Investlgatton, In my opinion death occurred at
<br />and due to the cause(s) stated. (Signature and Tllle) • o ° p ~me, date and place d due t the ause(s) slated. (Signature and Tnle)
<br />o ~
<br />r '- o C+
<br /> ~ t~.
<br />U O
<br />26. Dlb 70&4000 USE CONTRIBUTE TOTHE DEATH? 28a. HAS ORQAN OR TISSUE pONATION BEEN CONSIDERS 28b. WA CDN ENT ORANTED7
<br />Q YES NO ^ PROBABLY U UNKNOWN U YE5 NO Nol Applicable If 28a Is NO ^ YES ^ NO
<br />27. NAME, TITLEANDADDRESSDFCERTIFIER(PHYSICIAN,CORONER'S PHYSICIANORCDUNTYATTORNEY)(TypeorPnnl) 909 C1V1C Center
<br />Maine X. Roffman, MD Coroner's Physician Omaha NE 68183
<br />28a. REGISTRAR'S SIGNATURE 28b. pATE FILED 8Y REGISTRAR (Mo., Day, Yr.)
<br />tip, AUG 2 8 2006
<br />
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