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STATE OF NEBRASKA -` ' ' �"
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH_ANDYt'�J�9�1, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WTTH THE NEBRASK,Q ��]4iR7�J��117" CJ� YIF�1�,�l� AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR-V7�'�1� EE� $., .•';•'�, �
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<br />i � ��. ,�,
<br />DATE OF ISSUANCE ' `' � `�� -�}. <-' -' �� ,
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<br />����O���JL �T�kEY�G OP
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<br />09/20/2010 A ' r�r� r ��i' ";��'� ' `.
<br />� L�EP,ART����� ;A1�7' � � �
<br />LINCOLAI, NEBRASKA HUI�IV S�R1�'G� � ` ' ' �'r +�`" '
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SEI�;VICHS,' � p��y i �' ,,�a� �;'� � � 0256�
<br />CERTIFICATE OF DEATH ' -.� ,' `S� <<� ' •... � ° •, ..,� �� ��
<br />1. DECEDENTS-NAME (First, Middle, Last, SufFlx) 2. SIX ", '; �, � DATE OF,DEATH (Mo., Day, Yr.)
<br />Gabina Guerrero Mendez
<br />Female ' y`�- `- September 11, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF B1RTH 5a. AGE - Last BlRhday b. UNDER 1 YEAR 5c. UNDER � DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(Nre•) MOS. DAYS HOURS MIN3.
<br />Grand Island, Nebraska 73 December 7, 1936 �
<br />7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
<br />50&54 Hosarra. � Inpaderrt OTHER ❑ Nursing Homell.TC � Hospice Facllily
<br />8b. FACILITY•NAME (If not Instltution, give street ami number) � ER/OutpatleM ❑ DecedenYa Home
<br />�
<br />� Saint Francis Medical Center ❑ DOA ❑ anertspeciry�
<br />� ec. CITY OR TOWN OF DEATH (Include 2ip Code) 8d. COUN7Y OF DEATH
<br />c Grand Island 68603 Hall
<br />� 9a. RESIDENCE�STATE 8b. COUNTY 9c. CITY OR TOWN
<br />Z Nebraska Hall Wood Rfver
<br />LL 8d. STREET AND NUMBER e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY UMITS
<br />� 107 East 7th St. 68883 � ves ❑ n►o
<br />� 10a. MARITAL STATUS AT TIME OF DEATH Marrled
<br />� � ❑ Nevar Married 10b. NAME OF SPOUSE (First, Mlddle, Last, Suffbc) H wffe, �Ne maiden rmme
<br />� ❑ nnamaa, b�c saper�caa ❑ v�naowad ❑ Dlvorced ❑ Unknown p,� M Mendez
<br />d
<br />� 11. FATHER'S-NAME (Flret, Middle, Lask SufFlz) 12. MOTHER'S-NAME (First, Middle, Malden Sumama)
<br />m Francisco Guerrero Emestine Cantu
<br />Q ' 13. EVER IN U.S. ARMED FORCEST Give dates of service ff Yes. 74a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />6
<br />� �rea, No, or Unk.) NO Alejo Mendez Husband
<br />,g 15; METHOD OF DISPOSITION 18a. EMBALMER�SIGNATURE 18b. UCENSE NO. 18c. DATE (MO., Day, Yr.)
<br />F � Burial ❑ Do�Uon TYaCB DI@�
<br />❑ Cremauon Q EMombmant y 1328 September 14, 2010
<br />❑ Removal 76d. CEMETERY, CREMATORY OR OTHER LOCATION CITY f TOWN STATE
<br />❑ Other (Specify)
<br />St. Mary's Cemetery Wood River Nebraska
<br />17a. FUNERAL HOME NAME AND MAILIN� ADDRESS (Street, Clty or Town, State) 17b. Zip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />CAU E OF DEA See instructlons an exam les
<br />1& PART I. EMerthe ahain oT eve�s--diseases, Injudes, o� complicatlorre-that dlrecfiy cauaed the death. DO NOT eMer terminel eve� such ae cardfac erreet, ; AppROXIMATE INTERVAL
<br />reepiratory arteet, orveMrlcWar flbrllla8on without ahowing the etlology. DO NOT ABBREYUITE. EnOer only orte cause on a Urre. Add adtlWonal lbrea H nacassary. �
<br />IMMEDIATE CAUSE: ; onset to death
<br />IMMEDIATE CAUSE (Final a) R Middle Cerebral Artery Cerebral Vascular Accident ? 3 Days
<br />dlseaseorcondfdonresuWng �
<br />�� d �'� DUE Tp, OR AS A CONSEQUENCE OF: ! onset to death
<br />SequettNaity Ilatcondidona, e b) Diffuse Vascular Disease E Chronic
<br />airy, leading to the cause listed
<br />on Une a
<br />DUE T0, ORAS A CONSEQUENCE OF: ; onset to death
<br />Frrter the UNDERLYING CAUBE C �
<br />(dl�ease orinJurythatinklated
<br />the aveme reawtlng in death) DUE TO, OR AS q CONSEQUENCE OF: 7 o�et to death
<br />� d)
<br />�
<br />18. ;PART II.OTHER SIGNIFlCANT CONDITIONS-Conditiona coMribudng to the death but not resultlng In the underiying cause givan In PART I. 19. WAS MEDICAL EXAMINER
<br />End Stage Renal Disease On Hemodialysis, Insuifn Dependent Type II Dfabetes OR CORONER CONTACTED7
<br />� ❑ ves � n►o
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJU 21c. WAS AN AUTOPSY PERFORMED9
<br />� � NM P�e9�ent withln pase year � Natural � Homicltle � DrtvaqOperator R
<br />� � PregnaM et tlme oT death �� p�ltlent '� Pending Inveatlgatlon ❑ P8��8� �� � NO
<br />a � Not pregnant, but prepnaM wifhin 42 days of death �$„��ae � Couttl not ha determfired � P��" 27d. WERE AUTOPSY FINDINGS AVAILABLE
<br />� (] Not�pregnant, 6ut pregna�rt 49 daya to 1 year before death � Other (spee�ty) TO COMPLETE CAUSE OF DEATH?
<br />m ❑ Unknown H pregnaM within the paet year Q� YES � MO � - -�
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, fdrm, street, factory, of(Ice bullding, construction ske, ete. (Specify)
<br />$
<br />.� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F
<br />❑ ves ❑ No
<br />?2f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYffOWN STATE ZIP CODE
<br />23a. DATE OF DEATH {Mo, Day, Yr.} � 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� � September 11, 2010 � �
<br />� } 23b. DATE $IGNED (Mo., Day, Yr.) 23c. TIME OF DEATH ��� 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E c, Z Se tember 13, 2010 03:40 AM g� a Z
<br />�� $ � 9d. To tha best af my knpwietlge, death occurred at the 8me, date and place $ � 24e. On the basis M examinatlon and/or Investi aqon, in
<br />a n d d u e t a t h e c a u s e( s) a t a t a d. ( S I B� re a n d T I G e) ��$ � q�. ��d place and due to the cau�fs) eteted. (Signature a d TIUe� �
<br />~ Richard Fruehling, MD � � ;
<br />25. DID TOBACCO USE CONTWBUTE TO THE DEATH7 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTEDI
<br />❑ YES � NO � PROBABLY � UNKNOWN � YES � NO NotAppilcable H28a Is NO � YES ❑ NO
<br />27. E, TITL D ADD SS O ERTI E(PH S IAN, C S ANT, CORO E S P S R GO A RNEIry (Type or PriM)
<br />Richard Fruehling, MD, 2116 W Faldley #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE �y 28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />September 14, 2010
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