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Stat NIP STATE OF 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 DATE OF ISSUANCE 8/17/2017 LINCOLN, N.SRASKA 20170 CERTIFICATE OF DEATH STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES STANLEY S 'COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES .ci r 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Abbie Dawn Vialpando 4, CITY :AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Grand island, Nebraska 7. SOCIAL SECURITY NUMBER 505 - 15.2225: 8b. FACILITY -NAME (If not Institution, give street and number) 105 East Green Street 9a. RESIDENCE -STATE Nebraska 1 oa. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but Separated '❑ Widowed ❑ Divorced ❑ Unknown 13 EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes,' No, or Urlk.I No 15. METHOD OF DISPOSITION E Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal 0 Other (Specify) DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease of osyury tli8t initialed the eve;itts resulting >ht d , DUE TO, OR AS A CONSEQUENCE OF: usr d) 23a. DATE OF DEATH (Mo., Day, Yr.) August 2017 23b. DATE WINED (Mo., Day, Yr.) August 13,2017 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES NO ❑ PROBABLY ❑ UNKNOWN 23c. TIME OF DEATH 01:38 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) Ryan'Ramaekers, MD 5a. AGE Last Birthday (Yrs.) 32 9b. COUNTY Hall 28a. REGISTRAR'S SIGNATURE 6 5b. UNDER 1 YEAR MO 8c. CITY OR TOWN OF DEATH (Include Zip Code) Wood River:; 68883 9d. STREET AND NUMBER 105 East Green Street 16a. EMBALMER - SIGNATURE Tracey Dietz DAYS 9e. APT. NO. 2. SEX Female 5c. UNDER 1 DAY HOURS MINS. 9f. ZIP CODE 68883 14a. INFORMANT-NAME Jay Vialpando 16b. LICENSE NO. 1328 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska 3. DATE OF DEATH (Mo., Day, Yr.) August 11, 2017 6. DATE OF BIRTH (Mo., Day, Yr.) July 30, 1985 8a. PLACE OF DEATH HOSPITAL Inpatient ❑ ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC E Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Wood River 9g. INSIDE CITY LIMITS E YES ❑ NO lob. NAME OF SPOUSE (Fir,: Jay Vialpando Middle, Last, Suffix) If wife, give maiden name 11. FATHER'S -NAME (First, Middle, Last, Suffix) Steven Powell I " 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Kathleen Livingston 14b. RELATIONSHIP TO DECEDENT Spouse 16c. DATE (Mo., Day, Yr.) August 15, 2017 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Wood River Cemetery Wood River STATE Nebraska 17b. Tip Code 68801 CAUSE OF DEATH (See instructions and examples) 1H. 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, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Breast Cancer, Metastatic disease or condition resulting APPROXIMATEINTERVAL:: onset to death 3 Years pt Sequentially liht cor diaons,jf -. <))) any, leadinglo the cause hated • on line a DUE TO, OR AS A CONSEQUENCE OF: onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19, WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ENO 20. IF FEMALE: Not pregnant within past year ❑ Pregnant at time of death ❑ Nat pregnant; net pregnant: within 42 days of death 0 Nat pregnant,iut pregnant 43 days to 1 year before death ❑ Lin knema H pregnant within the past year 21a. MANNER OF DEATH E Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger 0 Pedestrian 0 Other {Specify) 21c. WAS AN AUTOPSYFERFORM €D? ❑ YES E NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? :22e. DESCRIBE HOW INJURY OCCURRED ❑YES [,J NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY /TOWN STATE ZIP CODS 24c. PRONOUNCED DEAD (Mo., Day, Yr. DEAD 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24d, TIME PRONOUNCED. 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) 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES E NO Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Ryan Ramaekers, 2116 W. Faidley Avenue, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 15, 2017 CD C