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:41811P,INIIiasuaiSltF0iV,ili4Yri('ri 8lY�x 55%ettgyfp�va � .r YNr - 55.E WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 12/7/2020 LINCOLN, NEBRASKA 202100181 SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 2016659 0 u 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Sally Kay Santis 2. SEX Female 3. DATE OF DEATH {MO., Day, Yr.). November 26, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH St. Paul, Nebraska 5a. AGE - Last Birthday (Yrs.) 72 5b. UNDER 1 YEAR 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 6. DATE OF BIRTH (Mo., Day,. Yr.) April 26, 1948 7. SOCIAL SECURITY NUMBER 507-56-0483 8b. FACILITY -NAME (Knot Institution, give street and number) Central City Care Center 8c. CITY OR TOWN OF DEATH (Include Zip Code) Central City 68826 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hat 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ❑ ER/Outpatient ❑ DOA 9c. CITY OR TOWN Grand Island OTHER E Nursing Home/LTC 0 Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH ll Merrick 0 Hospice Facility 9d. STREET AND NUMBER 1316 Howard Place De. APT. NO. 9f. ZIP CODE 68803 lg. INSIDE CtTY LIMITS YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated 0 Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Kenneth Lee Santin 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Arthur J ;Lynch Dorothy Peterson Middle, Maiden Surname) 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Kenneth Lee Santin 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION j Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER -SIGNATURE Stacie L Cook 16b. LICENSE NO. 1495 16c. DATE (Mo., Day, Yr.) December 2, 2020 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Fullerton Cemetery Fullerton STATE Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Alt Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 17b. Zip; Code 68801 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 it necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) COVID-19 disease or condition resulting In death) Sequentially list conditions, H any, leading to the cause 4Nred on 'Erie a, Enter tM UNDERLYING CAUSE (disease or Injury that Initiated INC events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: b) Dementia APPROXIMATE INTERVAL onset to death. <1 Week onset to death >6 Months DUE TO, OR AS A CONSEQUENCE OF: c) onsetMOtleath DUE TO, OR AS A CONSEQUENCE OF: 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 1. 19. WAS MEDICAL EXAMINER OR CORONERCONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not yregnant within peat year ❑ pregnant at time of death ❑-Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death ®Unknown if pregnant within the past year 21a. MANNER OF DEATH E Natural ❑ Homicide 0 Accident 0 Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 0 Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? O YES ENO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a, DATE OF INJURY {Mo; Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (SpeciM 22d. INJURY AT WORK? YES❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY:: STREET & NUMBER, APT.NO. CITY/TOWN STATE 21P,CODE! 0 23a. DATE OF DEATH (Mo., Day, Yr.) November 26, 2020 23b. DATE SIGNED (Mo., Day, Yr.) November 30, 2020 23c. TIME OF DEATH 03:39 AM 3d. India beat of myknowledge, death occurred at the time, date and place and due to the tause(s) stated. (Signature and Title) Brian K. Buhlke, DO 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES NO 0 PROBABLY 0 UNKNOWN 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 24e. On the basis of examination and/or Investiga Ion, In my opinion death occurred at INC. time, date and place end due to the causes) stated. (Signature arid Tale) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? DYES El NO 28b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES ❑ No 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Brian K. Buhlke, DO, 2510 18th Ave, Central Ci y, Nebraska, 68826 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) November 30, 2020 CO CA)