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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR4SfA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE,' WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANC
<br />4/15/2022.
<br />1NCOLN, NEBRASKA.
<br />202205324
<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 />ENT$ sIAME (FIS,.,.
<br />19 James ViPend
<br />4. CITY ANO STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last:Birthday,•
<br />Suffix)
<br />Hudson, South Dakota
<br />SQOIALSECURITY N(MBER
<br />i08 66-4872
<br />ACIL(TY-NAME;'(I
<br />Ion, give street and number)
<br />8
<br />CHI "Health St. Francis
<br />c. CITY ORTEAitffJ OP DEATH (Include Zip Code).
<br />Grand" Island 08803
<br />9a. RESIDENCESTATE ..
<br />iraska
<br />9d. STREET AND NUMBER.
<br />4207 Lariat Lane
<br />9b. COUNTY
<br />Hall
<br />6b.'UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />(Yrs.) MOS.
<br />71 >.
<br />DAYS
<br />8a PLRCE OF DEATH
<br />HOSPITAL Q I.npatler4
<br />E ER/Ou patient
<br />❑ DOA
<br />10a. MARITAL STATICS AT nme OF DEATH El Married 0 Never Married
<br />0 Married, but separated Q Widowed Q Divorced 0 Unknown
<br />F4THER'8-NAME (ir .' Middle,
<br />Jahn Robert Vipond Jr
<br />as
<br />Suffix)
<br />13. EVER IN U S ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or link.) Yes 03/08/1971-12/08/1972
<br />16. METHOD OF DISPOSITION
<br />© Burist ❑ 00neeton
<br />E;Crematio DSntomument
<br />❑iftemoval ❑Od+er{Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />22 04049
<br />3. DATE OF DEATH (IMF.,
<br />marchviI,:i:261T .:....
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />February 19:, 1951 >:
<br />OTHER 0 Nuraint Home/LTC
<br />❑ Decedent's Home
<br />Q Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />99 1p$ iECIkV t1fAiTS:;
<br />filo
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden
<br />Roxanne Sutton
<br />14a. INFORMANT -NAME
<br />Roxanne Vipond
<br />18a, EMBALMER -SIGNATURE
<br />Not Embalmed
<br />12. MOTHER'S -NAME (First, Middle,
<br />Mary Delores Seguin
<br />18d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />f. 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town. State);;,
<br />AP
<br />r u $ N)io e, 1123 W. 2nd, Grand Island, Nebraska for
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DA7
<br />March
<br />CITY / TOWN
<br />Gibbon
<br />TATE
<br />Nebraska
<br />17t412.ip;Gode.
<br />088€I1
<br />1a, PART I, Enter the chain of e4ente- 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 />IMMEDIATE CAUSE:
<br />IMteSpie ECAUS8 (Feral 'a) Sudden cardiac death
<br />disease or etindlttonrasulting
<br />in death
<br />saquentieity Oct conditions,,
<br />any, leading to the:cause gstad
<br />Min
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />))Unknown:,.
<br />Entrrt ..UNf3Ettt,VlNO. 11
<br />(dIseteeet injury that initiated:
<br />the events resulting In death),
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />death
<br />16. PART li OTHER S(QNIFICANT CONDITIONS.Conditions contributing to the death but not resWang In the underlying cause given In PART I.
<br />Hyper‘eIon i
<br />IF FEMALE
<br />Q .brat pregnant gdthlr pf
<br />Q Ptagnadtst#imeardaath.
<br />❑ .bhAl,.ptegnanl, but pregnant wttltln 42 days of des
<br />gQ Not pregnant, but pregnant 43 days to 1 year before death
<br />c Q Unknown if pregnant wlthln the peat year
<br />URY AT WORK;
<br />YES ,Q NO
<br />21a. MANNER OF DEATH
<br />E Natural Q Homicide
<br />0 Accident 0 Panu Lig InvestIgatlon
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />21b, IF TRANSPORTATION INJURY
<br />Oriver/Operetor
<br />QPassenger
<br />Q Pedestrian
<br />Q
<br />Other (Specify)
<br />19. WAS MEDICAL BxA 1INER.
<br />OR CORONER coNTACTab1.•
<br />E vas Q No
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />I:3 YES giNIi
<br />21d. WERE AUTOPSY FINDINGS AVAI
<br />TO COMPLETE CAUSE OF DEATH?
<br />13 YE 0 N
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction site, eWIttirielf#P
<br />e. DESCRIBE HOW INJURY OCCURRED
<br />22f LOCATION OF INJURYSTRTREET & NUMBER, APT.NO.
<br />a.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 13, 2022
<br />CITYITOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.) ,
<br />JVISIe,9114 922
<br />sd To:th5hes#M!ny.knowtedge, death occurred at the time, date and place
<br />and due tit theeause{s) stated. (Signature and Title)
<br />Nicholas M Cox,; MD
<br />23c. TIME OF DEATH
<br />09:25 AM
<br />.25 -DID TOBACCO U$E CONTRIBUTE; TO THE DEATH?
<br />❑ YES (NO El ?ROBABLY Q UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OPDEA'
<br />24d. TIM
<br />CODE ;}
<br />34 Oa the baels of examination and/or investigation, In my opinion death ogaar+ed st
<br />the time, date and place and due to the cause(s) stated. (Signature add TIS)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES ( NO
<br />7 NAME TITLS;ANDADGRESS OF CERTIFIER (Type or Print >:
<br />Nitioias Vl•Cox, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRAIL
<br />Not Applicable If 28a is NO
<br />28b. DATE FILED BY REGISTRAR (Mo , Day, Yr.)
<br />March 17, 2022
<br />is
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