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WHEN 'PIIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA 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 />STATE OF NEBRASKA
<br />4,15ksit ,istrft3Rlmepisv „cr9M sir, tz,. k owto'(if i3: >:
<br />DATE' OPISSUANCE
<br />3/2012024
<br />LINCOLN, NEBRASKA
<br />202401500'
<br />BOHNENXA
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />1. gegsneNVS'-NAME (First, Middle, Last, Suffix)
<br />Sandra Jean Saladen
<br />CERTIFICATE OF DEATH
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Council Bluffs, Iowa
<br />$#yCIAf, S.ECURITtl NU.eER
<br />485-88.3697
<br />6a, AGE - Last`Birthday
<br />(Yrs.)
<br />62
<br />8b. FACILITY -NAME Of not Institution, give street and number)
<br />Grand Island Regional Medical Center
<br />se. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a` RESIDENCE -STATE
<br />Nebraska
<br />Sd STREET AND NUMBER;
<br />1207 Lilley>Street
<br />9b. COUNTY
<br />Hall
<br />too. MARITAL SYATnISAT TIME OF DEATH ] Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER'S -NAME (First, Middle, Last, Suffix)
<br />William Eugene Huff Sr
<br />13. EVER IN US, ARMED ..FORCES? Give dates of service N Yes.
<br />(Yes, No, or link~) No
<br />16. METHOD OF DISPOSITION
<br />❑;Burial ❑ Donation
<br />t Cremation 0 Entombment
<br />❑'Rem•oval•❑ Other' (Specify)
<br />Sb.'UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Sa. P. LADE OF DEATH
<br />• HOSPITAL inpatient
<br />❑ ER/Outpatient
<br />D DDA
<br />9c. CITY OR TOWN
<br />Wood River
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH (Moi,
<br />March 8, 2(:424
<br />OTHER 0 Nursing Homo/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />Ile. APT. NO.
<br />92 ZIP CODE
<br />68883
<br />1000'.
<br />AYE
<br />10b NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Tracy Saladen
<br />14a. INFORMANT -NAME
<br />Tracy Saladen
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'SNAME (First Middle,
<br />Rthanne Collins
<br />18d. 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 Falths<Euneraf Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />net and examples)
<br />Maiden Surname)
<br />IT'ir UMI1
<br />14b. RELATIONSHIP TO DECEt1Efir>
<br />Spouse
<br />16c. DATE (M?., Day,Yr.);,
<br />MarchMarch,liii02W
<br />1Tb. ZIR Ca
<br />CAUSE OF DEATH (See (nstrucft
<br />3. PART k Enter the chain of events -diseases, Injuries, or complicatlonrthat 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 tines if necessary.
<br />disease or se
<br />in dotth#
<br />tU (Emil '
<br />dkiort reeuhlnt
<br />IMMEDIATE CAUSE:
<br />a) respiratory failure
<br />DUE TO OR AS A CONSEQUENCE OF:
<br />Sequentially eat conditions, if b)Small cell neuroendocrine carcinoma of lung
<br />any, loafing to the moo tiled
<br />wear tier uNl}BN YINti QAu
<br />(aiaaes see inj
<br />the events resulting In do
<br />LAST
<br />ur'thin ink/died
<br />TO, OR AS A CONSEQUENCE OF:
<br />DUE TO, OR A CONSEQUENCE OF:
<br />d)
<br />APPA
<br />I onset
<br />3 Days.
<br />TIMATE INTERVAL
<br />onset to death
<br />1 Month
<br />18 FART B OTIfER 5fGN($CANT CONDITIONS -Conditions contributing to the death but not resuhkig iR 9te utrdsrlying cause given in PART L
<br />20 IF: FEMALE:
<br />Notpregnanf.wit in past year
<br />•
<br />❑:<Irre sfeleofdeatEF.
<br />a Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown Ifpregnantwthin the past year
<br />TE cin INJURY (MOS, Day, Yr.)
<br />224, INJURY AT WORK?
<br />OYES 0 NO
<br />21a. MANNER OF DEATH
<br />Natural ❑ Hondaide
<br />❑ Accident.
<br />❑ Pending Invastlge ion
<br />0SuiciM ❑could not be determined
<br />22b. TIME OF INJURY
<br />21b. (F TRANSPORTATION INJURY
<br />❑ Ddtft1Operetor
<br />Passenger
<br />❑ Pedeatrlan
<br />❑ Other (Specify)
<br />19, WAS MEDICAL EXAMINER
<br />OR CORONER.CONTAC OD?
<br />❑ YES ®H0
<br />21c. WAS AN AUTOPSY PERFOR
<br />❑ YES f1 NO.
<br />21d. WERE AUTOPSYFINDINOS AVAILABLE,
<br />TO COMPLETE CAUSE OF DEATH?
<br />22c. PLACE OF INJIJRY.At home, farm, street, factory, office building, constructions
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22fLQCATIQN OP INJURY;;. STREET & NUMBER, APT.NO.
<br />3a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 8, 2024
<br />CITYITOWN...
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />Meath 11 :::2024 08:36 AM
<br />To the best of my knowledge,. death occurred at the time, date and place
<br />and duo to the eause(s) stated. (Signature and Title)
<br />Devin Scott, APRN
<br />N
<br />STATE
<br />-24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b, TIME OF DEATH
<br />24d. TIME PRONOUNCED
<br />24a. Qii the ,sums of examination andlor Investigation, In my opinion desgl pM04tted at
<br />*Bryn age and place and due to the cause(*) Meted. (SigmNure and Tis)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES bZ,] NO
<br />27iIAM4,'nTLEAND ADDRESS OF CERTIFIER (Type or Print
<br />[Sevin eco APRN, 3533Pra(rieview St, Grand Island, Nebraska, 68803
<br />26. DID Tri
<br />CA YE
<br />BACOQ USE CONTRIBUTE TO THE DEATH?
<br />0 NO'LX PROBABLY ❑ UNKNOWN
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO 0 YES
<br />28b. DATE FILED BY REGISTRAR (Mo., C
<br />March 15, 2024
<br />Yr.)
<br />
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