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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPYC RR ES THE RAISED SEAL OF STATE OF NEBRASK 4r IT CE! TIFIES THE DOCUMENT BELOW TO
<br />SEA.TRUE COPYOF,TI'IE ORIGIIiiAL RECORD ON FILE WITH TIT NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFSSUJANCJ»
<br />7i1 "If2i}22 ' `
<br />LINCOLN, NEBRASKA
<br />202205989
<br />IIC.4& J! "aa, .4.! ‘41,1'.4 f
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. D EC NT; NAM# (FFIst, Middle, Last, Suffix)
<br />Tracy GaSflene Millet
<br />4, Cr•ORTERRITORY,OR
<br />TY AND STATE
<br />FOREIGN COUNTRY OF BIRTH
<br />Afro€a, Colorado
<br />7. SOCIALSEO tJRFTY HUMBER
<br />Q5-044715
<br />5a. AGE - Last Elrthday
<br />(Yrs.)
<br />d'
<br />E
<br />A
<br />8b. FACILITY -NAME or not Institution, give street end number)
<br />115 Lakeview Circle, Apt. 12
<br />CITY ORTYWN OF DEATH (Include Zip Cods)
<br />Orarid Islet). -;'66S03
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />d.;STREET AND NUMBER
<br />115 Lakeview Circle
<br />55
<br />5b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a, PLACs OF pEATH
<br />HOSPITAL (3 Inpatient
<br />0 ER/Ou patient
<br />9b. COUNTY
<br />Hall
<br />tAARITAL $TA nJS AT TIME OF'DEATH ❑ Married ❑ Never Married
<br />Married, butseperated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (FiistY; Middle, Lest, Suffix)
<br />Edwin MasDn .:;•
<br />1 J EVER IN U.S'. RMED FORCES? t
<br />(Yea, No, or Unk.) No
<br />18. METHOD OF:DISPt pll.T)ON
<br />❑;Burial(Donation
<br />J i remetlotf; (Entombment;;
<br />Removal ( Other (Specify
<br />e date
<br />of service if Yes.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />22 09302.
<br />3. DATE OF DE4T14 (Ma., Oay Y#
<br />• June,l5' 022
<br />6, DATE OF SIRTMi (' o., Dsy, Yr;)•
<br />OTHER ❑NursingHomoiLTC
<br />-
<br />E Decedents Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />90. APT. NO.
<br />12
<br />10b. NAME OF SPOUSE (First, Middle,
<br />Kevin L Miller
<br />14a. INFORMANT -NAME
<br />Kevin L Miller
<br />185. EMBALMER -SIGNATURE
<br />Stacie L Cook
<br />9f. ZIP CODE
<br />68803
<br />Suffix) If wild, give maiden
<br />12. MOTHER'S -NAME (First, Middle,
<br />Norma Jorgensen
<br />ed. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a..Ft .NERAL:HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />All Faiths tf:ntsral Home, 2929 S. Locust::Street, Grand Island, Nebraska
<br />CAUSE OF; DEA1H'(See iristruCtlons and exam)
<br />T I. Enter the.
<br />respiratory erre
<br />•16b. LICENSE NO.
<br />1495
<br />CITY/TOWN.
<br />Gibbon
<br />les)
<br />dri. iN3}tlE;t
<br />I Yes
<br />146, RELAT(ONS!I
<br />Husband
<br />DENT
<br />16c. DATE (Mo Day :Yr.).
<br />June 22; 2022
<br />t of events. aleeeatas, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE+:Apersist.
<br />Mesa or 0e41 44 resbislia
<br />tit death}
<br />Sequendelly
<br />Ilst condlaons,.if
<br />any. teeginy to tnm neons tistad
<br />IMMEDIATE CAUSE:
<br />a)Asphyxiation
<br />DUE TO, ORAS A CONSEQUENCE OF:
<br />b)Oxygen Deprivation
<br />the events resu
<br />LAST
<br />OR AS A CONSEQUENCE OF:
<br />death) DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />1s88i3'1 ;
<br />APPROXIMATE'1NTE1
<br />tmsettadea#t.
<br />Minutaf3
<br />VAL
<br />etteistee death
<br />Minutes
<br />18 PART it O'
<br />CPAP not I
<br />Q. lF'FEMALE:
<br />ttot pto9nttnt;rddi(ll paat;y is
<br />Pregnant at sitrre 1f deadt
<br />tddt pre nant tion plophant volt)/11:42 days of death
<br />❑ Not pregnantitxtipregnant 4S days"id'( year before.=
<br />(#lilknown If R?egnant Within the past year
<br />R SIsNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the
<br />Ilied; multiple Medications
<br />ATE
<br />•II JURY iMo Day, Yr.)
<br />22e.
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />❑ Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be determined
<br />nderlying cause given In PART I.
<br />22b. TIME OF INJURY
<br />CRIBE HOW INJ
<br />21tt IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />Passenger
<br />0 Pedestrian
<br />0 Other (Specify)
<br />19. WA$ -MEDT A1„EXAMU' ER
<br />OR CORI NER OONTACTE0? '
<br />( YE$" ❑ NO
<br />21c. WAS AN AUTOTRSY: PERFORMED?,
<br />YES lar NO,
<br />21d. WERE AUTOPSY FINDINGS Alt.ABLE
<br />TO COMPLETE:CAUSE OF DEATH.?
<br />•E]YES
<br />22c. PLACE; OF INJURY -At home, farm, street, factory, office building, construction site, etc #Specify)
<br />URY OCCURRED
<br />22f.::LOCATIONOF INJURY: STREET & NUMBER, APT.NO.
<br />DEATH Mo.) DAY, Yr.)
<br />23b. DATE SIGNED (Mo., Day,'Yr.)
<br />CITY/TOWN::
<br />23c. TIME OF DEATH
<br />To tkte east .M In knowiedge,:death occurred at the time, date and place
<br />add due to the
<br />taunts) stated. (Signature and Thiel
<br />26. DID TOBACCO USE OONTRIBUTE`TO THE DEATH?
<br />❑ YES 0 NO 0 PROBABLY ® UNKNOWN
<br />STATE
<br />24a. DATE SIGNED(Mo., Day, Yr.)
<br />July 8, 2022
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />June 15, 2022
<br />24b. TIME OF DEATH
<br />Unknown
<br />24d. TIME PRONOUN
<br />02:36 PM
<br />�iP trODE .:;
<br />34e. Cnthe basis of examination endlor Investigation In my opinion i eat{t asalirred
<br />the ante, date and place and due to the cause(s) stated. (Signet teeddd T(i)e)
<br />Sydney K Pfeifer, Hall County Deputy Attorney
<br />EEN CONSIDERED?
<br />28b. WAS CONSENT GRA
<br />Not Applicable if 28a Is NO
<br />NFP„O?
<br />❑.'YES IX(Iv
<br />SUE DONATION B
<br />❑NO
<br />2? NAME, TIT4E AND:ADDRESS GF CERTIFIER (Type or Print
<br />Sidney K.P#eifer, Hall County Deputy Attorney, 231 South LOcust, Grand island; Nebraska, 6880
<br />2ga 28b. DATE FILED BY REGISTRAR (Mo., Day Yr )
<br />July 8, 2022
<br />REGISTRARS SIGNATURE
<br />26a. HAS ORGAN OR TIS
<br />E YES
<br />
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