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STATE OF FLORIDA <br />THIS DOCUMENT HAS A LIGHT BACKGROUND ON TRUE WATERMARKED PAPER. HOLD TO LIGHT TO VERIFY FLORIDA WATERMARK. <br />IlU <br />0 <br />0 <br />IIt° ° 0°00 ° '�'l <br />0 ° o <br />°tTOIFICAT I1000 lliD <br />o 0 <br />° ° ° o ��Jl 1' ° 0 <br />0of °VITALST <br />STATE FILE NUMBER: 202013205$ <br />DECEDENT INFORMATION' <br />11N°1I11iMARION ALPHO��NSEI iDIEK <br />III IIIID IVIIUI I` <br />° <br />1111111 ` E OF DEATH: JU 10 111' <br />BIRTHPLACE: LADATE OF BIRTH:MA ,93YWR <br />PLACE OF DEATH: INPATIENT <br />FACILITY NAME OR STREET ADDRESS: BRANDON REGIONAL `HOSPITAL <br />LOCATION OF DEATH: BRANDON, HILLSBOROUGH COUNTY, 33511 <br />111110ESIDENCE: 8919 P AY BOULEVARD, LAN iIIG'LAKES, FLORIDA 34 <br />11111 11 1 OCCUPATION, IND1 V:I11111111 p11 <br />EDUCATION: M 4014115 DEGREE <br />HISPANIC os H IAN -ORIGIN? NO, NO ;1,QF HISPANIC/HAITIAN Ywu <br />X11116 ��:;�� , �.., ,.,Illld <br />RACE: WHITE <br />SUIR i, „ING SPOUSE /IIPARENT NAME INFORMATION <br />IPRIOR TO FIRST AGE, IF APPLI <br />, gull (I ! <br />1111 �RITALSTA S: M IR N 1111 <br />�� �i <br />I SURVIVING SPOUSE NAME: VERONICA RO LEY <br />FATHER'S/PARENT'S NAME: HUBERT CLEMENT OSTDIEK <br />MOTHER'S/PARENT'S NAME: LOUIS CLAIRE BROCKMAN <br />IFORMANT, FUNERAL FACILITY At PLACE OF DISPOSITION I <br />INFORMANT'S NAME; PUL OSTDIEK <br />11111 <br />�II1 <br />n ! RELATIONSHIP Tp DECEDENT: SON AV <br />INFORMANT�IIIIIIIIII {DRESS: 8523 WHEA'ifI�I�IfLD WAY,' ELLICOTT CI RYLAND 21043, <br />FUNERAL DIRE OR/LICENSE NUMBER: ANTHONY VALLEJERA,111'1 86749 <br />FUNERAL FACILITY: LOYLESS FUNERAL HOME F331136 <br />5310 LAND a LAKES BLVD, LAND O' LAKES, FLORIDA 34630, <br />OF DISPOSITION: C 'PION hull II11 <br />E OF DISPOSITIONEIIIIWIATION TRIBUTE <br />1111 1 <br />II <br />r,1 111' <br />11111111 111 V1P'III i�11I I'"PETERSBURG, I•�W� ID <br />CERTIFIER INFORMATION <br />TYPE OF CERTIFIER: ASSOCIATE MEDICAL EXAMINER <br />TIME OF DEATH (24 HOUR): 0905 <br />CERTIFIER'S NAME: MARY KATHRYN'. MAINLAND <br />IpERTIFIER'S LICENSE NUMBER: ME103006 III II <br />NAME OF ATTENDING PHYSICIAN (IF OTHER THAN CERTIFIER):NOT A71111Fli1:11LIC <br />ABLE <br />CAUSE OFi'�I'AND INJUlio ' NFORMATION q IIhlhl luu II� III V II IIL <br />MANNER 'OF_DIEAH: NATURAL III <br />CAUSE OF DEATH - PART 1- AND APPROXIMATE INTERVAL: ONSET TO DEATH <br />a. CORONAVIRUS DISEASE (COVID-19) <br />MEDICAL EXAMINER CASE NUMBER 201306608 <br />DATE CERTIFIED: JULY 22, 2020 <br />UNKNOWN <br />1 PART II )THER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING IN THE UNDERLYW <br />ARTERIOSCLEROTIC AND HYPERTENSIVE CARDIOVASCULAR DISEASE TH ATRIAL FIBRILIOITI! <br />FAILURE 1 1 1 q 11111111111hilll <br />1'11111111h 11 <br />USE GIVEN IN PART 1: \ <br />AND CHR NIC RENAL <br />AUTOPSY P� �1III�JJII IU#ED2 NO UIIII III AUTOPSY F N I GB AVAILABLE TO c V PLETE CAUSE OF <br />DATE OF SUR®C DID TOBAC CI 5E CONTRIBUTE TO DEATH? NO ; <br />REASON FOR SURGERY: <br />PR GNANCY INFORMATIONN <br />IN4URY: NOT AP I,II <br />TION OF INJURY <br />I IIII 11 <br />p; sop DESCRIBE HOW INJURY 1CICURRED: <br />APPLICABLE <br />E,IIIGF INJURY (24 HOU <br />PLACE OF INJURY: <br />IF TRANSPORTATION INJURY, STATUS OF DECEDENT: <br />11 <br />TYPE Of VEHIC <br />- 1111h1 <br />, 111111 <br />0 <br />° �� ''� ° 000 1 '1 °" o 0 <br />TATE REGISTRAR I4I 1I 1 INfil�I <br />Ilio 00 ° 0 0 °°0 o 0o)0 °6 C� <br />O 0 0 ° <br />O 0 o <br />0 <br />E ABOVE 8I0NATUlIP CERTIFIES THA <br />o '' °, THIS 60y;M <br />ANING: sem. <br />0 0 0 <br />11 <br />1 <br />1 <br />1 <br />TH <br />A <br />* 5 8 <br />O 0 <br />IS A TRUE ANL ,CORRECT 9OPV 0% THE OFNICIAL RECORD ONdIpN THL OFFICEO <br />MINTED O1i PUOTJ)COP r Iµ, II ' CUpITV PAPERQNt$i q I j r THS G AT 0 <br />OF FUU8RIDA. DO l 00 �i ITHHd6UUTT VERIFYING Thi, ,V=A'TERD i,� IIf <br />MEt'I• FACE I ON SS A' L ICOLORED SACKGROG r r nl r , I • • =9E 8EAOMI) <br />OMICFL THEBACIC(�+��(��►All 8I IALLINE3 TgCf0TH�'¢�I ilnNi why 11 IIII <br />'r'f <br />COPY '". O 'I' 1 III' 1 ° II1II IIII11 <br />116111131 0 <br />0 0 0 DH 8947 (084' - 0 I 0IIII <br />11 ,..il ''' CERTIFICATION OF VITAL RECORD <br />0 5 1 4 * <br />0 <br />