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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OP NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OR THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFF I$$IfAN1E
<br />7/22/2022
<br />LINCt LN, NEBRASKA
<br />202206699
<br />i �ei.
<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. DECEDENV:$.NAME (First, Middle, Last, Suffix)
<br />Barbara Jean :Huxtable
<br />4, cirY AND STATE OR TERRITORY, OR
<br />Grand Island, Nebraska
<br />goci SEp€IRITY.IVIIM$ER
<br />506.464334
<br />REIGN COUNTRY OF BIRTH
<br />6a. AGE • Lastgirthday
<br />(Yrs.)
<br />8b. FACILITY -NAME (if not Institution, give street and number)
<br />8520 90th Road
<br />70
<br />Sb UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8e.PLACE OF:DEATH
<br />HosPiTA4 ❑ Inpatient
<br />❑ ER/Outpatien
<br />❑ DOA
<br />OTHER 0 Nursing Horrta/LTC ''
<br />ER/Outpatient
<br />6c :CITY OR OF DEATH (Include Zip Code)
<br />WOod Rine 68553
<br />911. RESIDENCE -STATE
<br />Nebraika
<br />9d:S'TREETAND NUMBER
<br />5520 S 90th Fond
<br />9b. COUNTY
<br />Hall,
<br />10 , 11ARITAL 51ATU6 AT TIME OF DEATH.® Married. 0 Never Married
<br />Marrieif but separat d ❑ Wldtiwed 0 Divorced0 Unknown
<br />11. FATHER`S I4AME 4l ..t, Middle, Last, Suffix)
<br />.�Geol 'D Allan 'Jr
<br />13: ,:••••• IN, Ii ARMED FQ!
<br />(Yes, No, or Unk.) NO
<br />15. METfhOD OF .ISPQSITN
<br />Burial ❑ Din
<br />❑i:Crematron ❑ Entombment
<br />❑''Removal ❑Otirer(Specify)
<br />17a.. FUNERAL::HOME;
<br />Apfel Funeral H
<br />lye: dates: of fie Ice if Yes.
<br />9c. CITY OR TOWN
<br />Wood River
<br />HOURS
<br />MINS.
<br />3. DATE OF DEA'f40d•, Ray
<br />July 12,, 2E22
<br />6. DATE OF MIRTH (Eta:, Dey
<br />July 14 1951 <>.
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />8e. APT. NO.
<br />9f. ZIP CODE
<br />68883
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give
<br />Dennis L Huxtable
<br />14a. INFORMANT -NAME
<br />Dennis Huxtable
<br />16a. EMBALMER -SIGNATURE
<br />Chris McCoy
<br />16d. CEMETERY, CREMATORY OR OTH
<br />Wood River Cemetery
<br />9S
<br />SIDE! CtTY Aare "
<br />)IE8 NO
<br />12.t4OTHER'S,NAME (First, Middle, Malden )
<br />Dolores Greenwood
<br />16b. LICENSE NO.
<br />1191
<br />LOCATION CITY / TOWN
<br />Wood River
<br />NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />onne, 1123 W 2nd, Grand Island, Nebraska
<br />14b. ftELA11ONsid
<br />pouse
<br />18c DATE ;Mo.. Day, Yr-),:
<br />July ie,
<br />CAUSE OF DEATH (See instrtrdtIons and examples)
<br />1$. PART I. Eater the chalnof events- diseases, Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory Street, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines If nese
<br />IMMEDIATE CAUSE:
<br />DIATE CAUSE (PillsE.
<br />"(MI! nr Sdri ilNOn resulting
<br />n deettt}
<br />sequendallyfiataendxtona If::
<br />any,.teadit ¢ hecaueeiis d
<br />e) Stage IV metastatic breast cancer
<br />LAST
<br />....... ...... ....
<br />...............
<br />....... ..............
<br />.................
<br />ttE'ftNO:'CAiiSi
<br />:that tnntatS4
<br />king In deeih)';
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />18 PARTII OTHER SIGNIFICANT CONDITIONS-Condidons contributing to the death but noire
<br />AIZIO. !a Claeim10ntia;:h}tpBltBns[q#1
<br />26. IF FEMALE:
<br />Nat pregnant aaat;"a
<br />511::
<br />PregneeifettTme et Oath
<br />a NetMittenafE but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />iinlvtoam g pregnerd wttta t the peatlyear
<br />22a :D•
<br />ATE QE IN4UftY (Alli
<br />22d. INJURY AT WORK?
<br />❑ YI~s::.❑ NO
<br />21a. MANNER OF DEATH
<br />IE Natural ❑ Homicide
<br />0 Accident ❑ Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />icing
<br />22b. TIME OF INJURY
<br />n the Underlying cause given In PART I.
<br />21b. IF TRANSPORTATION INJURY
<br />© DriverlOperator
<br />`❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />fsto, C ALEx ,MINER ,:.
<br />t R CORQi ISI/: TAC'1'E71"
<br />ayes 1 J NO
<br />21d. WERE *N AIME-ABLE
<br />TO COMPLETE CAUSE OP DEATH?
<br />❑ YES i_71a0
<br />22c. PLACE OF INJURY At borne, farm, street, factory, office building, construct,
<br />22f (.00ATiON OF IAIJURY..: STREET '& NUMBER, APT.NO.
<br />23a. DATE Ol DEATH (Mo., Day, Yr.)
<br />July 12, 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />JON 141022
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />05:42 PM
<br />0. 4W b4etotstlxti owledge,;death occurred at the time, date and place
<br />end dud tette cause(e) elated (Signature and Title)
<br />Stelren Hun, MD
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />YES
<br />01 PR PROBABLY 0 UNKNOWN
<br />MOT: :. }+ i ADRESS OF CERTIFIER (Type or Print
<br />Steven Husen, HID, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.),
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b.T1M
<br />f DEATH
<br />ZIP
<br />DE•
<br />24d, TIMEPRONQ(AHOED DEAD:..
<br />i
<br />24e. Olt the basis of examination end/or investigation, In my % meat oiwwned'il
<br />the time, date and place: end due to the icause(s) steted.I$ AN flt)e
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ] NO
<br />26b. WAS CONSENT GRANTI09 :»
<br />Not Applicable if 28a 101 NO YE
<br />28a. REGISTRAR'S SIGI
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />July 19, 2022
<br />
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