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WHEN THlS CL�PY CA/�3 THE RA/SED SEAL OF THE IYEHf7ASKA HEAlTH AND F,LWY��k�EB��','S
<br />SYS1"EA�, IT CERT�S THE BELOW TO BE A TRUE COPY OF THE bRIf�INA,k R�@�l.�Q Qy €ll:�411/JH .:;'
<br />THE NEBRASKA HEAL 1"H AND HUMAN SERVICES SYSTEM, V/TAL STAT/STI�S �FJOAI, �F1 /S
<br />THE LEGAL DEPOSlTORY FOR WTAA. RECQRp3. 7_ ���
<br />DATE OF /SSUANCE 2 O 1 0 V 9 2 8 v �� --
<br />� C g � �00� /�����F?�1� �
<br />q�3l�Afi�� �'TA�'�' i5�ld�$�R�R �
<br />LINCOLN, NEBI7ASKA H�Er41.TH AND Hl�����1�-
<br />STATE OF NEBRASKA- DEAARTMENf OF HEALIH AND HCJMAN SER1�fA1��C�A�"S�PORT
<br />VITAL STA'I'IST(CS - - � � 01115
<br />CERTIFICATE OF DEA'TH �'
<br />1. �ECEDENT - NAME FIR5T . MI�DIE LAST �� 2. SEX �� �� 9. pATE OF DEATH lMonM. Dav. YearJ .
<br />Eli�io De Tor San�os, .Tr. Male February l, 2003
<br />: 4. pTY ANp SYA7E OF gIRTH /nrrof in US.A.. name countryl Sa. AGE - Last B�idhday uNDER 1 VEAf7 11NDER t PAY 6. DATE OF BIRTM /Monfh. Oay. Year/
<br />Derby, Texas �r,5.i sb Mos i PAYS sc.HOUas' ""�"s MSTCh lfi� 1921
<br />7. SOCIAL SECURTIV NVMBEq B�. PLACE OF �EA7H
<br />467�-40-6363 HoSP�TA�. ❑ mpatient OTHER � Nurs�ngHomo
<br />8h. FAC�uTV-Name /1lnalrn.stth�tpn,give5lreglarndnumber) � EROulpatient � aesidence
<br />St. Francis Skil led Ca Center ❑�A ❑ ana��s���Y�
<br />BC. CIYV TOwN OR I.00ATION OF DEATH 8tl. INSI�E CITV LIMIT$ Ba. COUNTy OF DEATH
<br />Grand Island `'e9 � No ❑ Ha11
<br />9a. RESIOENCE - STATE 96. COUN7Y 9t. CITV, TOWN UR LqCATION 9d. STREET AN� NUMBER llncludingLp Cada O b O 7 9s. INSIDE CITV LIMITS
<br />V C7 O J
<br />Nebx'aska Hall Grand Island 2805 W. Capital Ave. rBS� No ❑
<br />70. FACE -(a.g., White. Black. American Indian. 11. ANCESTRY le.g., �lalian, Mezican, German, elcl �2 � MARRIED ❑ wi00WED 13 NAME OF SPOUSE p� wile. givemaiden namel
<br />BIC.IISpecilyl ISpeCdyl NEVER pIVORCEO
<br />His anic Mexican Mq Carmen Herrera
<br />taa. USUAL OCCUPATION lGive kind p! wprk p�re duri� mosl 146. KINO OF BUSINESS INDUSTRV 15. EDUCATION �Sqauty only hlghe5t grede completedl
<br />Wxvrkmg/ilp.evgnilreh'redJ � Elementaryor5econdary10��2) ' Collegell-aor5-�
<br />Cement Finisher Concrete Manufacturin 8th Grade
<br />18.fATHER•NAM@ FIRST MIpOLE LAST 17 MOTHEF FIRST . MI�OLE MAIDEN SURNAME �
<br />E�i io Santos, Sr. Emete�ia De1. Toro
<br />18. WAS �ECEASEO EVER �N V.S. ARME� FORCES? 19a INFOFMANT - NAME .
<br />�VgS. no. or �nk.� Uf yea. give war end datas W aervicasl �
<br />No ----_----� Carmen Santas
<br />19q. INFORMANT MAILING ADDRE55 ISTREET OH A.F.b. Np., C17Y Oi1 YpWN. STATE. ZIP) T
<br />28 W. ap Ave., Grand zsland, I�ebraska 68803
<br />20. E ER - SIGNATU 8 LI E �� 21a. METHOD pF DISPOSITIDN 216. �ATE 21c. CEMETEqV OFl CREMAIUHV � NAME
<br />C]e��;,, [�Re,„o�a, Feb. 5, 2003 Westlawn Crematory
<br />. - ME 21d. CEMETERV Of7 CREMATORY LOCATION C11Y OH TOWN STATE
<br />Livingstan-Sondermann F •H• �Crema�ion �Donauon ��and Island, Nebraska
<br />226. FUNERAL HOME A�ORESS �STFEET OR R.F,D. NO.. CI7V OR 70WN, STATE, ZIP) �
<br />fi01 N. Webb Road, Grand Island, Nebraska 68803-4�50
<br />23 IMMEDIATE CAUSE (ENTER ONLV ONE CAUSE PER LINE FOR Ial. 16�, ANO �c�� � Interval botween onset and dea�h
<br />PART l I
<br />�k ' iai �c.tu-�cn�^'u �'I 5 ��, __ �...I-- � `""'"��( .
<br />' Dl1E TO.OR A$ A CONSEOUENCE OF� � . I Interval belween vrwa� and aealn
<br />� I
<br />I
<br />M (bl I
<br />I DUE TO, OR AS A CONSEOUENCE OF�. T �^� � �� :me�vat petween w:se1 and nea�h
<br />i
<br />I
<br />Icl I
<br />OTHER SIGN�FICANT CON�ITIONS - Contlitipns coniribuGng lo the deeth bW nM rBlated PART III IF FEMALE. wA5 YHERE A 24. AUTOPSV 25. wAS CASE REFERRED TO MEDICAL
<br />PART PFEGNANCV IN YHE pAST 3 MONTH57 EXAMINEF OR CORONER�
<br />II
<br />(Ages 10-54� YBS No V9s Nv �� Yes NO
<br />26a. 28b. 4AtE OF INJUR� lMa.OdV. Yr.) 28c. MOVA OF INJURY 26d. �ESCRIgE HOW INJVRV OCCURRE�
<br />� Accidem � Undatarminetl M �
<br />�� Suicide � Pending 28e. INJURV A7 WDAK 261. PI� QP • p,t homa, farm. sVeet. faclory 26g� LOCA71ON � STREET OR R.FD. NO. CITV OR TOWN S7ATE� �{
<br />� ❑ ❑ ❑ o �ce budding,etc /Specity/
<br />womiciea Investigation Yas No
<br />27q, OATE OF �EATH /MO.. Dey. Y�.) 28a. DATE SIGNE� (MU.. Uay. YI.) 28b. 71ME Qf DEATH
<br />- �- a/�/d� ��� M
<br />��`��' 27n. bAYE SIGNE4 I�.. Osy. ���1 27c. TIME pF �EATH ��� 28c. PRONOUNCED OEA� /Mo.. Oay, Ycl 2Bd. PRONOUNCE� DEAD (Houd
<br />_ � � � �� °�� 3 �a � U-� ° y-� _ �1 M � � � � M
<br />� 27d. To the beat ol my knowledge, d9atn pccurred at ihe tima, ale and pl�ce and eue iv me �� Q 28e. On the basis of examination andror investigation, in my opinion death occurrBd a�
<br />� �y usols) stalgd. q /j� Ihe lime, tlate and place and due ro the cause�s� stated.
<br />�� , �5� nature and Tille � � � ��(/�� ` � /� � � � , ISi nature ana Title
<br />29 �IO T08AGC0 USE CONTRIg ME bEAT ? .a NAS ORGAN OR TISSVE bONATION BEEN CONSI�ERED� 30.b WAS CONSENT GRANTE��
<br />. V VES � �NO � UNKNOWN� � � VES NO � � VES � Np
<br />� y_»
<br />31. NAME ANO AD,� OF CEFTIFIER IPHVSICIAN, COFONER�S PHVSICIAN OR COUNTY ATTORNEYI l crPrinq �
<br />�" �� F� rC �C � F�n 7 � G f /l,l C-U, � ✓:v+�� 1 'j jr � ^�[ C' ���..��.�
<br />32a. REGISTRAR r„ 326. DATE FILED BV REG�STqqq /Mo.. Oay. Vc/
<br />a{� �,;'d�� � � . �.: ,.r � ,� FEB 5 2A03
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