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<br />iaAu , el( yrrnt 1 I,� ar,uBa„fit , ,l,ai(,r M� Nllr�!liil ell..;:.
<br />STATE OF NEBRASKA
<br />r1115117lf1ital, 21117ap3i.
<br />.IMP/iHri ap
<br />pit „lr..
<br />llt/HEN THIS COPY CARRIESTHE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />EEA TRUE COPY OF 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 />DTE OIr:ISS
<br />9/2.1.0
<br />LINCOLN, NEBI3A'
<br />20220736
<br />s
<br />M4"
<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. pecans,NV$-NAME ;Fkst, Middle, Last, Suffix)
<br />I Rbsalene Josepitlne Huffman
<br />'4 CITY AND STATE ORT.ERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />lrasiCl
<br />stiOIAt. SECURITY 0geeR'
<br />506-284660
<br />8b. FACILITY-NAMEllfatit IniatItutIon, give street and number)
<br />1 CHI Health St.Francis
<br />Ba.AGE LAMleIrthday
<br />(Yrs )
<br />94
<br />UNDER 1 YEAR
<br />MOS.
<br />Rea. PLACE QF DEATH
<br />HOspITAL ❑ Inpatient
<br />® ER/Outpatient
<br />0 DOA
<br />Sc. ITYOR TOWN OFDt ATH (Include Zip Code)
<br />11n Grand Island 888033
<br />9a. RESIDENCE -STATE
<br />Nebraska.'
<br />9d. STREETAtItt NQMT9ER
<br />947 Oalr .Street
<br />DAYS
<br />9b. COUNTY
<br />Hall
<br />10a. MA1tITAL STAT(1$ ATTIME OF DEATH 0 Married ❑Never Married
<br />0 Married, but separated Igi Widowed 0 Divorced 0 Unknown
<br />11. FATHER S..NAME t 2rst, Middle, ' Last, Suffix)
<br />Walter Olson
<br />13. EVER IN U.S< ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unit.) No
<br />15. METHOD OF DISPOSITION
<br />ritJ Bufial ]itonatton
<br />l Crematlen.: QEntombrsent
<br />� [] Removal � 3Rtttar ($peciryr)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />2212845
<br />3. DATE OF DEATi (Nto, Days"
<br />September '1:x;.2022
<br />& DATE OF 8IRTii halo.,
<br />Y 14, 19
<br />OTHER 0 Nursing Home/LTC.
<br />❑ Decedent's Hoare
<br />❑ Other (Spey)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE;
<br />68801"
<br />(DEC:
<br />70b NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, ghee maiden
<br />Forrest Huffman
<br />12 MOTHER'S -NAME (First, Middle,
<br />Esther Aiden
<br />14a. INFORMANT -NAME
<br />Richard Ray Huffman
<br />16a. EMBALMERSIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />Maiden Surname)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION.
<br />Central Nebraska Cremation Services
<br />17a FUNERAL HOME NAME. AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral dome, 2929 S. Locust Street, Grand Island, Nebraska
<br />14b: RELATIONSMP TOOWE PENT
<br />Son
<br />16c DATE (Mo Day Yr )
<br />September 14, 2922
<br />CAUSE OF DEATH (See lnstructione and examples)
<br />18. PART 1. Enter the chain of events- -diseases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines'. If necessary.
<br />ip iMeriMltArEtrAU5E{Ftrtei
<br />dIthp eorCamdi6fipitreaUifing
<br />in degth)
<br />Sequentially pet otefdiilop 11 ,
<br />any, ieadhtg to tiro: cause (rated
<br />;:on Keir a
<br />Ent004.4400.0 )N6GAVSE;
<br />(dlaeeeaoriyuty hatintf6atad
<br />athe events resulting In death)
<br />4 LAST
<br />m
<br />S. PART II.;OTtt
<br />OMNI
<br />IMMEDIATE CAUSE:
<br />a) Severe protein calorie malnutrition
<br />E TO, OR AS A CONSEQUENCE OF:
<br />advanced dementia
<br />1T.2laOotIs
<br />APp180XIMAT1511511ffill
<br />onset poi
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />ANT CONDrONS-Conditions contributing to the death but not; resulting
<br />20. IF FEMALE,:
<br />Q Hotgregnant`w
<br />�^{, t?ragnamatt&ae ofx{eatti:
<br />Ntd pragrat# iiut pregimiiiwlthln 42 days or death
<br />0 Not pregnant; but pregnant 43 days to 1 year before death
<br />Unknown a pragnaMwl hln. the past year
<br />A
<br />2a giATEOFtr RY(5144j:ley,Yr.)
<br />22d. IS/JURY A1' VVOICt?
<br />■ ■ NO.
<br />;QCA110N.O
<br />8.
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />'❑ Accident 0 Penang Investigat
<br />0 Suicide ❑ Could not be determined.
<br />22b. TIME OF INJURY
<br />22c. PLACE OF IN
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />21b. IF TRANSPORTATION
<br />D Dri iirperator
<br />f+assenger
<br />© Pbdestden
<br />❑ Other (Specify)
<br />INJURY
<br />19. WAS MEDICAL;:ExAN)IN
<br />OR CORONER CONTACTEi
<br />® YES C3 NO
<br />21c WAS AN AUTOPSY P61'
<br />YES ..
<br />21d. WERE AUTOPSY FINDINGS'AtfiiifkASEiE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />URY•At hone§, farm, street, factory, office building, construction site, ONS):
<br />EET';8i NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 13, 2022
<br />CITYJTQWN
<br />23b. DATE SIGNED (Mo„ Day, Yr.) 23c. TIME OF DEATH
<br />Sliilo<tember15.2022 07:30 AM
<br />23d, TOR* best of m;! knowledge, death occurred at the time, date and place
<br />anti due talkie a useis)stated. (Signature and Title).
<br />Srikanth Reddy Kothapalli, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />b. TIME OF DEATH
<br />24d. TIME PRONOUNCED. DEAD.
<br />24e Olt the belie of examination and/or investigation, hi my opktionaaRh abcuited at
<br />m thee, deb and place and due to the cause(s) stated. ISlgnatu eaattTlei:
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN QR TISSUE DONATION BEEN CONSIDERED?
<br />El YES ❑ NO I `PROBABLY ® UNKNOWN 0 YES El NO
<br />27 N.1ME, ?ITI; AND AD6 ESe OF CERTIFIER (Type or Print
<br />Srlkanth Raddy.Kothapalti, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />.1
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO YES
<br />28b. DATE FILED BY REGISTRAR (Ma, Day, Yr.)
<br />September 21, 2022
<br />
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