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DATE OF ISSUANCE 10/13/2015 LINCOLN, NEBRASKA STATE OF NEBRASKA 201605793 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALMAND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBK4 * OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO2VFN AiLEY' S. tO 'R -. 43gSI$TANTY'SIXTEREGIS pEFAR1E 1 WALT?, 7 �+1a STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN'SE4Vff CERTIFICATE OF DEATH 15 05824 1. DECEDENTS-NAME (First, Middle, Last, Suffix) David Emil Salzsieder 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Aberdeen, South Dakota 7. SOCIAL SECURITY NUMBER 504 -64 -8991 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE -STATE Nebraska 9d. STREET AND NUMBER 1416 W. Koenig St. 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER'S -NAME (First, Middle, Last, Suffix) Dean Salzsieder 12. MOTHER'S -NAME (First, Martha Hauck Middle, Maiden Surname) 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. (Yes, No, or Unk.) No 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: a) Respiratory Failure APPROXIMATE INTERVAL onset to death Hours IMMEDIATE CAUSE (Final disease or condition resulting in death) Sequentially list conditions, if any, leading to the cause listed on line a DUE TO, OR AS A CONSEQUENCE OF: b) Chronic Obstructive Pulmonary Disease onset to death Years DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c ) (disease or injury that initiated onset to death the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given In PART I. Sepsis 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant at time of death 0 Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? DYES ❑ NO 9b. COUNTY Hall 16a. EMBALMER- SIGNATURE Not Embalmed 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 22b. TIME OF INJURY 5a. AGE - Last Birthday (Yrs.) 63 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH cc r E u i °u � 0 23d. To the best of my knowledge, death occurred at the time, date and piece $ and due to the cause(s) stated. (Signature and Title) � g 1 28a. REGISTRAR'S SIGNATURE id 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient II ER/Outpatient ❑ DOA THE ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) ❑ Hospice Facility 9c. CITY OR TOWN Grand Island 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Rebecca Lynn Cotman 14a. INFORMANT -NAME Rebecca Lynn Salzsieder 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 5b. UNDER 1 YEAR MOS. DAYS 9e. APT. NO. 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR ❑ YES ❑ NO ❑ PROBABLY ® UNKNOWN DYES TISSUE El . • ATION BEEN CONSIDERED? 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 8d. COUNTY OF DEATH Hall 16b. LICENSE NO. 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 3..DATE,OF'DEATH (Mo., Day, Yr.) September 29, 2015 6. DATE OF BIRTH (Mo., Day, Yr.) November 25, 1951 9f. ZIP CODE 68801 1 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) October 1, 2015 17b. Zip Code 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 24a. DATE SIGNED (Mo., Day, Yr.) October 7, 2015 24b. TIME OF DEATH 06:36 PM 2 4d. TIME PRONOUN 24c. PRONOUNCED DEAD (Mo., Day, Yr. CED DEAD September 29, 2015 06:36 PM 24e. On the basis of examination and /or investig tion, in my opinion death occurred at the time, date and place and due to the cau e(s) stated. (Signature and Title) Emily A. Beamis, Hall Deputy County Attorney 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Emily A. Beamis, Hall Deputy County Attorney, 231 S. Locust, P. O. Box 367, Grand Island, Nebraska, 68802 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) October 8, 2015 1