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�VWAP '57doiltb. » I ". MAO STATE OF NEBRASKA 0 PART 1. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, raspiratdry arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. iMMECIATE CAUSE: a)Acute Cholecystitis With Cholecystectomy IMMEDIATE CAUSE (Final disease or condition resulting 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. DATE OF ISSUANCE 8/1/2017 LINCOLN, NEBRASKA WHEN :' THIS " COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS 23a. DATE OF DEATH (Mo., Day, Yr.) June 11, 2017 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH June 12 2017 03:07 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 1 AO[111.0Sh T. Kolli, MD 2t:a. Y.A C'P 1RN.:L R TISSUE t' .;_», h.'` ❑ YES E NO ❑ PROBABLY ❑ UNKNOWN I E YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) Abhilash T Kolli, M D, 2300 S 16th, Lincoln, Nebraska, 68502 28a, REGISTRAR'S SIGNATURE ^ &.2 25. Iiitb YORACCits USE CQ$TRiBUTD 70 THE 0E47.17 201705262 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH CITY /TOWN STATE ate STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUN DEAD 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) .OMSIESRED? 28b. WAS CONSENT Gnrz1TEO? Not Applicable if 26a is NO ❑ YES E 28b. DATE FILED BY REGISTRAR (Mo, June 14, 2017 b. FACILITY.NAME (If not Institution, give street and number) Bryan Medical Center East 0G re • 8c. CITY OR TOWN OF DEATH (Include Zip Code) • Lincoln 68506 9a. RESIDENCE STATE Nebraska LL' 9d. STREET AND NUMBER • 5418 Homestead Ct. .0 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Randy Howard Reeder 4. CITVAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand Island, Nebraska 7. SOCIAL SECURITY NUMBER 505 -82 -6393 10e. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married 0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 11. FATHER S -NAME (First, Middle, Eldon Arthur Reeder Last, Suffix) 4 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Delores Patricia Otto 13, EVER IN U.S.' FORCES? Give dates of service if Yes. (Yes, No, or Unk:) No 15. ME1'HOt OF DISPOSITION ❑ Burial ❑ Donation E Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 9b. COUNTY Lancaster 5a. AGE - Last Birthday (Yrs.) 58 MOS. 8a. PLACE OF DEATH 511. UNDER 1 YEAR 9c. CITY OR TOWN Lincoln 16a. EMBALMER- SIGNATURE Not Embalmed DAYS 9e. APT. NO. HOURS 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Alternative Funeral & Cremon Services, 245 N. 27th Street. Suite B, Lincoln, Nebraska CAUSE OF DEATH (See instructions and examples) 2. SEX Male 5c. UNDER 1 DAY MINS. HOSPITAL Inpatient OTHER ❑ Nursing Home /LTC 0 ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 14a. INFORMANT -NAME Corrine Rae Reeder 3. DATE OF DEATH (Mo., Day, Yr.) June 11, 2017 6. DATE OF BIR June 20, 1958 (Ma.;•Day, Yr.) ❑ Hospice Facility 8d. COUNTY OF DEATH Lancaster 9f. ZIP CODE 68521 9g. INSIDE CITY LIMITS ® YES ❑ NO 10b. NAME OF SPOUSE (First, Corrine Rae Frentz Middle, Last, Suffix) If wife, give maiden name; 16b. LICENSE NO. 16d. CEMETERY, CREMATORY OR OTHER LOCATION Lincoln Cremation Service CITY / TOWN Lincoln STATE Nebraska 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Day, Yr.) June 14, 2017 17b, Zip Code 68503 APPROXIMAT INTERVAL „4p vn i9alh 1 Day In:death) Sequentially ffst Cdnditlons, if any, leading to the cause hated on line a. DUE TO, OR AS A CONSEQUENCE OF: b)Septic Shock onset to death 1 Day Enter the UNDERLYING CAUSE Idiseaseorinjuryt}fat initlated ulting . in death) DICE TO, OR AS A CONSEQUENCE OF: c) Paraplegia C7 -T1 Spinal Cord Injury the events re LAST ;! DUE TO, OR AS A CONSEQUENCE OF: d) onset to death I' 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. Pulmonary Embolism, Deep Venous Thrombosis, Chronic Decubitus Ulcer 20. IF FEMALE: 0 Not pregnantwithin past year ❑ Pregnant at time of death ❑ Not Pregnant, but pregnant within 42 days of death ❑ Nat pregnant, but pregnant 43 days to 1 year before death ❑ Unknown if Pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. (tiJURYATWORK? (� Y£S ] NO 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 21a. MANNER OF DEATH Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger 0 Pedestrian 0 Other(Specify) onset to death 15 Years 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 111 NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAUSE OF DEATH? .. ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) ZIP CODE