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<br />STATE OFNEBRASKA
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<br />74EN THIS COPY CARATES THE RAISED SEAL OF STATE OF NEBRASKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TI1 E COPY OF ME 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 />:BATE OF ISSUANCE
<br />.1 /1.14°,2023
<br />IJNCOLM,'NEBRaASI.
<br />202300...33
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGI
<br />DEPARTMENT OF HEAL?
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE: OF DEATH
<br />1 DECEDENVS :k E (F rat,.:.Middle,
<br />Ann Marie .Vredeveld
<br />Last, Suffix)
<br />&Ci YAND STATE OR`.TERRITORY; OR FOREIGN COUNTRY OF BIRTH
<br />Orlawa .lo.wa
<br />T 5'r(IAL SECURITY NUMBER:
<br />48 -64-8524
<br />Sb.'FACILITY NAME (if pot I)5titutlon, give Street and number)
<br />•Cllr (BElltfk,$t Ftarlols:"
<br />5a. AGE Last 'Birthday '.5b.'UNDER 1 YEAR
<br />(Yre.) MOS. DAYS
<br />7$
<br />s5. PLAGE OF:DEAT
<br />tt0 t Q)
<br />inPatleht
<br />0 ER/Outpatient
<br />CI DOA::.
<br />2. SEX
<br />Female
<br />9c CITY ORtQWN OF DEATH'(Ingludatip,Code)
<br />Grand island 68803
<br />Se. RESIDENCE•$TATE''::
<br />Nebraska ,
<br />lid ;ST'REETANNUMSER::<.,
<br />8:1OQ W•HoSker Highvv
<br />Sc. UNDER 1 DAY
<br />HOURS MINS.
<br />3.'DATE OF DEATH linty.; pay,
<br />Decetribet.l4., :2022
<br />8..DATE OP BIRTH".(MAo., Day, `Yr.
<br />Ootober 80:;:464t
<br />OTHER 0 Nursing Home/L
<br />❑ Decedent's Homo:
<br />❑ Other. (Specify)
<br />I Fest Hty
<br />9b. COUNTY
<br />Hail
<br />10a MARtTALSiATUS 1 1 ME OF: DEATH L,J Married 0 Never Married
<br />Married, but separated l Undoyied 0 Divorced 0 Unknown
<br />11 FATHER S,IAE.I
<br />Ltoyd Gray
<br />60 444 U.S.' At.10#0 •
<br />FORCEt9?
<br />,tYttsi No. or.Unk) NO r' "_ ..
<br />15 AQ ETHOOOF:tusiO,Sf[CtN
<br />p r�tilial Deffalten
<br />J Crematltyn 0 Entombment
<br />Reittovtd j Othe(spec
<br />rify)'
<br />Give da
<br />Suffix)
<br />of service If Yes.
<br />$e. APT. NO.
<br />8f. ZIP CODE
<br />68810
<br />10b NAME OF SPOUSE (First, Middle, Last, Suffix) If wife,give *aiders t}
<br />John Vredeveld
<br />12 MOTHER°& NAME (FIrst, Middle, Maiden Surname)
<br />Margaret Maxwell
<br />13'
<br />14a. INFORIVIANT-NAME
<br />Raymond Thomas Vredeveld
<br />18a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />Ind. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1 Ta FUNERAL HAMS NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Ail Faiths 1<urteral Meme: 2929 S Locust Street Grand Island Nebtaska
<br />t&' PART LE
<br />espl
<br />CAUSE OF DEATH.{See listru
<br />18b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />RELATIONSHIP
<br />1itx 2'3p
<br />6880
<br />one and examples)
<br />r..the 'Magri of ch Sts.: -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />entrieidar fibrillation without chewing the etiology. DO. NOT ABBREVIATE. Enteronly one cause one line. Add additional Tines If neoeseary.
<br />IMMEDIATE CAUSE:
<br />Acute hypoxic respiratory failure
<br />Sequentially:gat condhiona, if:
<br />#ey, leading to the yatue Bated
<br />UE TO, 'OR,AS A CONSEQUENCE OF:
<br />)COVID 19 infection
<br />Enter;3he UND LYlNOdA
<br />• (disease.tfr INtirytkitt inkF
<br />resulting Mdeat
<br />UE TO,:OR AS A CONSEQUENCE OF:
<br />DUE•TO, OR A CONSEQUENCE OF:
<br />18. P.,RT Il OTHER SIQNfi ANT CONDITIONS -Conditions contributing to the death bunt*resulti g III the underlying cause g
<br />fraiiity MalnDunshmerit.
<br />2U IFfEMALE :>
<br />n Plot pregnant:within peat yes .:.
<br />❑ pregnant at lime ofdeeth
<br />�` 8 pregnant, Ind QregnaMwithlo 42 days of death
<br />preeriOt. bid 0494k 4$ days tat 'Year before death
<br />Utdmown N pregnatd w thin the peat year
<br />•32a .:DA
<br />INJURY(MA'Day Yr_)-:
<br />22d:INATW
<br />JURY (RK? '.:,:
<br />NO
<br />LOCATION .• If
<br />21a. MANNER OF,DEATH
<br />Natural ❑ fHandpide
<br />❑ Accident 0 pending Inveafigation
<br />0 Suicide 0 Could not be determined
<br />22b. TIME OF INJURY
<br />22c. P
<br />229. DESCRIBE.HOW INJURY OCCURRED
<br />URT STREET &NUMBER, APT.NO..
<br />DATE OP;DEATH (pilb.,,pay, Yr.)
<br />December 14,2022;.
<br />23b DArE SIGNSG (Mo., Dey_'Yr.►'.
<br />De+r�rttbej 9 2922''
<br />To #is beet of y•knowledge, death occurred at the time, date and place
<br />and:dub toth$ lauae(a) seined.(Signature and Title)
<br />rikantli Reddy Kothapaili, MD
<br />SOF INdlRY At hS
<br />cITYITO Si
<br />23c. TIME OF DEATH
<br />12:24 PM
<br />2d Dip TOBACCO USE CONTRIDUTE'TO:THE DEATH?
<br />YES ❑ NOPROBABLY [J UNKNOWN
<br />n in PART I.
<br />211x. IF TRANSPORTATION INJURY
<br />Driuei.'/Operator
<br />Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)•
<br />10.'WAS ME
<br />OR COitONEI
<br />®Y�$
<br />EXAMINER.... '
<br />coNTACTED?
<br />21d. WERE AUTOPSY. Mtn AvAttAttO
<br />TO coMRI.ET'E CAUSE OFIN?
<br />D YES CFR
<br />et, factory, office building, const
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TI
<br />OF DEATH
<br />24d, TIME -PR'
<br />24etill the 4aala of exeminagon and/or inveatigation, bt my opinttoa.al
<br />the thug 'date and place and due to the cause(s) stated. (Signature a
<br />285. HAS ORGAN OR TISSUE: DONATION BEEN CONSIDERED?
<br />❑ YES ®NO
<br />27 NAM'rITLEAND ADDRESS OF CERTIFIER (Type or Print
<br />Snkarith'Reddyittothapalli, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803
<br />253. WAS CONSENTGRAN%ED? ::::
<br />Not Applicable If 280 *NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr,
<br />January 3, 2023 . '
<br />
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