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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />EE A TFFUE COPY THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVIC; r, W.rAE. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />02207984
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<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES'
<br />STATE QF NEBRASKA . DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />NAME )(First, Middle, Last, Suffix)
<br />•
<br />Sue Vaiaaek
<br />4. CITE .AND s'IAtE OR:TERRrt
<br />Y, OR FOREIGN COUNTRY OF BIRTH
<br />H1astin9s Nebraska
<br />T SOCIAL SEGUR TY rtUMBE
<br />$0698-3615-
<br />8b. FACILITY -NAME Of not Institution, give street end number)
<br />•
<br />CH .Heaittt St Franc
<br />8a, AGE • Last Birthday.
<br />(Yrs.)
<br />62
<br />55b'UN11ER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />88. PLACE QP DEATH
<br />HOSPITAL ©inpatient
<br />0 ER/Outpatient
<br />DOA
<br />ghx'CITY OR tit Gitr OE#14 (Inelittie rep Cods)
<br />Grand lsfbrtd. 68803
<br />9e. RESIDENCE -STATE
<br />Nebraska
<br />00,PTR&BT4t::„„ ' '
<br />8400N E*uusStl
<br />9b. COUNTY
<br />Hall
<br />1ot. MArti.AL STATUSAT TIME OF DEATH ® Married 0 Never Married
<br />❑; Married, batt separated ;l{ Widowed ❑ Divorced, 0 Unknown
<br />11 FATHER S<NAME Feriae,
<br />Norbert
<br />18. E1ER tN U.S' APRMED FG
<br />of No, or Ink) No
<br />Middle, Last, Suffix)
<br />Given dates of
<br />rvice: if Yes.
<br />9c. CITY OR TOWN
<br />Cairo:
<br />1Ob. NAME OF SPOUSE (First,
<br />Randy - Valasek
<br />12. MOTHER'S -NAME (First, - Middle, Me
<br />. Katherine ' Loskill
<br />HOURS
<br />MINS.
<br />6.' DAT .
<br />May 21,1:.
<br />OTHER 11 Nursing Home/LTC
<br />❑ Decedent's
<br />❑ Other (SpeclfY)
<br />ad. COUNTY OF DEATH
<br />Hall
<br />8e. APT. NO. 9f. ZIP CODE
<br />68824
<br />Middle, Last, Suffix) If wife, give maiden naIlle
<br />14a. INFORMANT -NAME
<br />Randy Valasek
<br />16.
<br />5 METHOD OF 16a. EMBALMER -SIGNATURE
<br />j!BntlaE ❑Denatori.,; dot=Embalmed
<br />Cremtvtlotl t Entdxri invent 16d. CEMETERY, CREMATORY OR OTitER LOCA71(3N
<br />Rainovat ` ❑.r (Specify)
<br />Central Nebraska Cremation Services
<br />17a..F4NERAL HOMENA.ME AND MA OMADDRESS (Street, City or Town, State)
<br />Aid faith$ Funerat Orne 2929 S. Locust Street Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATQDISHIP
<br />Spouse
<br />16c. DATE
<br />AUG
<br />CAUSE OF DEATH (See Instructions and examolest
<br />18. PART L. Enter thechein of )stuns-. -rEaesaes, Injudee, or compiicatlone4hat directly caused the death. DO NOT enter terminal events such as cantles arrest, =` .
<br />respiratory sweet, ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />40NATE.0.418E0001 a) ge4,lungcancer
<br />Vase er oenetii0R resulthte .
<br />sequemiahy Iistoattlttiens,.lr.
<br />any, eadrns to Rha. )use lietap
<br />::.online
<br />Rntar d. P$DERi;Ylflf,
<br />(dtseagre 0r Injaty Heat i
<br />she evehte
<br />/eau ung tit
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR A CONSEQUENCE OF:
<br />c),
<br />TO, OR AS A CONSEQUENCE OF:
<br />IPL ,pAR1`ll O'Ino Slemeten$T CONDITIONS -Conditions contributing to the death but not rssult#ng In the underlying cause given In PART 1 t
<br />Chrorii Obistrflttive Pu monary Disease°
<br />45.1 -IF F.2MALE
<br />ltd pMg n*nt wl
<br />PrsgnBM of stat' of
<br />ffat pregnank but pre'ghAnt wfthhh 42 days of death
<br />Nat pregnant; bttt pregnant 4Se'aye to 1 year before death
<br />uaknewn 747aansntww1MIn the Past Y•
<br />ear
<br />22f 40CATIONOFi.,
<br />3a. DATE OF DEATH.(Mo., Day, Yeti).
<br />Airpi. st 14, 2022 `.
<br />21a. MANNER OF; DEATH
<br />El Natural u Hontkide
<br />❑ Accident ❑ Pendinglnveetigation
<br />❑ Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />Dib .,/operator
<br />Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />it tONTAf
<br />❑ YES , al NO
<br />21c. WAS AN AUTO S P.
<br />❑ YES
<br />21d AUTOPSY FINDINGS AVAILA
<br />TO COMPLETE DALKie OPDEATH?
<br />❑ Yes Q NO •.
<br />22c. PLACE OF ESL/UR -At home, farm, street, factory, office building, constntotion Wb ,eft (
<br />22e. RE3CRIBE HOW INJURY OCCtE RED
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />August -16. 2022 11:45 AM
<br />82d Ya)It4.babtof My Imptsftdpe,death occurred at the time, date and place
<br />shiib die lathe::sausels) stated. (Signature and Titre):
<br />Gary Settle, MD
<br />STATE
<br />24a. DATE STONED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />25 DID) TOBAC
<br />' YES
<br />US@ CQNTE $UTE TO THE DEATH?
<br />NO} PROBABLY ❑ UNKNOWN
<br />240. TIME OFDEATH
<br />2411. TIME P WNO.U..NCED DEAD:'...
<br />24e..dtr the baste of examination and/or Investigation, hf my optMett death 5Mlln}d et•
<br />the time, date and place and due to the cause(s) stated. (Signattee and.':ride)
<br />26a. HAS ORGAN; OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES ENO
<br />26b. WAS CONSENT GRAI
<br />Not Applicable if 26a Is NO
<br />NAMEOTIIR AND ADDRESS OF CERTIFIER (Type or Print
<br />Gary Seth, MD 2116 W Faid)ey #400, Box 9802, Grand Island, Nebraska, 68803
<br />28a REGISTRAR'S SIGNATURE
<br />4..11 �f
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 23, 2022
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