202109805 - Laserfiche WebLink

Browse

&VA �� STATE OF NEBRASKA -. A4RrrJJdDcfr is tllirafliiElln f mat8idd4dVt1 .:INGII'I iliAll. t-'. aAtAWddMMw a s. - ass y3,L Yix�...,sval•G:SV�":4x ii' - 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 RRCORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 7/15/2021 LINCOLN, NEBRASKA O w E 5 1 0 2 t v c;. o 202109805 -01 SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Randy. John Saathoff 4. CITYAND STATEOR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Franklin, Nebraska 5a AGE - LastBirthday (Yrs.) 64 5b. UNDER 1 YEAR 2. SEX Male 5c. UNDER 1 DAY MOS. DAYS HOURS MINS. 21 09016 3. DATE OF DEATH (Mo., Day, Yr.) July 7, 2021 6. DATE OF BIRTH (Mo., Day, Yr.) 7:' SOCIAL SECURITY NUMBER 50,E-80.3605 8b: FACIUTY•NAME (If not Institution, give street and number) 415 N. Custer.Avenue Sc city' OR TOWN OF DEATH (Include Zip Code) Grund Island 68603 9a. RE SIDENCE-STATE Nebraska 9d.<SSREET AND NUMBER 41 N. Custer Avenue 9b. COUNTY Hall 8a. PLACE OF DEATH HOSPITAL ❑' Inpatient ❑ ER/Outpatient ❑ DOA 10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married 0 Married, but separated 0 Widowed El Divorced 0 Unknown 9c. CITY OR TOWN Grand Island September 26;,1956 OTHER 0 Nursing Home/LTC Decedent's Home ❑ Other (Specify) I8d. COUNTY OF DEATH Hall 9e. APT. NO. 9f. ZIP CODE 68803 Hospice Facility 9g. INSIDE CITY LIMITS l YES ❑:;NO 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name 11, FATHER'S,NAME (First, Middle, Last, Suffix) John William Saathoff 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yet, No, or Unk.) No 12, MOTHER'S -NAME (First, Middle, Maiden Surname). I Norma Ann Killouoh 14a. INFORMANT -NAME Joshua John Saathoff 15. ME TROD OF DISPOSITION Burial ❑ Donation Cremation ❑ Entombment Removal` ❑ Other (Specify) 18a. EMBALMER -SIGNATURE Daniel D Naranjo 16b. LICENSE NO. 1071 14b. RELATIONSHIP TO DECEDENT Son 16c. DATE: :(MO., Day, Yr.) July 12 2Q21 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Central Nebraska Cremation Services Gibbon STATE Nebraska 17a.F JNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Ail Faiths Funerat Home, 2929 S. Locust Street, Grand island,' Nebraska 17b. Zip Cods ;:.. 68801 CAUSE OF DEATH (See instruttiorls and examples) 18. PAFT I. Enter the chain of events- .diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ref pfratory 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) Undetermined Natural Causes IMMEI1IATE CAUSE (Final disease or condition reaulgng Sequentially list conditions, if any, lording to the cause listed online a. Enter Ire UNDERLYING CAUSE (diseale or injury that initiated the events resulting in death) LAST DUE TO, OR AS A CONSEQUENCE OF: b) DUE TO, OR AS A CONSEQUENCE OF: c) APPROXIMATE INTERVAL onset to death onset to death` DUE TO, OR AS A CONSEQUENCE OF: d) onset to death 1 8, PARTE. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to ttte death but not resulting In the underlying cause given In PART 1. High Blood Pressure. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? YES ❑ NO 20. IF t\EMALE:. ❑ IMe pregnant within past Year P sertard at:Smoot death ❑:: Alt pregnant, but pregnant within 42 days of death 0 riot pregnant, but pregnant 43 days to 1 year before death 0 tArknowa florescent within the past year 21a. MANNER OF DEATH ka Natural 0 Homicide ❑ Accident ❑ Pending Investigation 0 Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger ❑'Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 14 NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a DATE OF INJURY (Ma., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -A me farm, street, factory, office building, construction site Specify) 22d. INJURY AT WORK? ❑ YES: ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LC CATION', OF INJURY STREET & NUMBER, APT.NO. 0. 23a. DATE OF DEATH (Mo., Day, Yr.) CITY/TOWN 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 23d. TO:the heat of my knowledge, death occurred at the time, date and place IMO the to the'cause(s). stated. (Signature and Title) STATE ZIP CODE 24a. DATE SIGNED (Mo., Day, Yr.) July 9, 2021 24b. TIME OF DEATH Unknown 24c. PRONOUNCED DEAD (Mo., Day, Yr.) July 7, 2021 24d. TIME PRONOUNCED DEAD 08:15 AIV) 240,0n the basis of examination and/or investigation, In my opinion ath rrccuried 4t Umbrae, date and place and due to the cause(s) stated. (Signature drat Tiae) Dave Medlin, Hall County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES ❑ NO '❑ PROBABLY ® UNKNOWN 27: NA SE, TI A}1D ADDRESS OF CERTIFIER (Type or Print Drve Medlin, Hall County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801 28a. REGISTRAR'S SIGNATURE 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑YES QNO 26b. WAS CONSENT GRANTED? Not Applicable If 26a is NO ❑ YES: NO 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) July 13, 2021 Albw