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WHEN THIS COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES <br />SYSTEM, IT CERTFF/E'S THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAT1SVCSatCRCW, WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />DATE OF ISSUANCE _ <br />200402387 MEE�!SCOOPER <br />NOV 6 2002 AssistAkIiii -s ►"EGfsTRAR <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERWGES- SYSTEM <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMANSE&WCES FINA19E AND SUPPOT 12589 <br />VITAL STATISTICS = <br />02 <br />CERTIFICATE OF DEATH <br />1. DECEDENT - NAME FIRST MIDDLE LAST <br />2. SEX <br />3 DATF OF DEATH /Moms. Day. Year) <br />John Dutch Vredeveld <br />Male <br />October 29, 2002 <br />4. CITY AND STATE OF BIRTH fHnot lin USA.. name coadtryl <br />Sa. AGE -Last Birthday I <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />16. DATE OF BIRTH (MO M. Day. Yowl <br />Almelo, Holland <br />(Yrs 15p <br />7 <br />SD MOS DAYS <br />Sc. HOURS' MINS <br />February 28 1943 <br />7 SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />485 - 504324 <br />HOSPITAL ❑ Inpatient OTHER ❑ Nursing Home <br />Accident Undetermined <br />❑ ER Outpatient -99-Restdence <br />8b. FACILITY - Name (if not insotuborl, give street and number) <br />1607 North H Road <br />❑ DOA ® Other (Specdv; <br />Sc CITY TOWN OR LOCATION OF DEATH <br />B I INSIDE CITY LIMITS <br />8e COUNTY OF DEATH <br />Phillips <br />Yes ❑ No X <br />Hamilton <br />9a. RESIDENCE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 19d. STREET AND NUMBER (fncluding Lo Codel ge McnnE CITY 1I"- <br />�"" uY l�j]m 5302 N. Ta >S 99901 Yes ® No ❑ <br />10. R. Black. American Indi an. <br />7(eg., <br />11. ANCESTRY fe.g.. Italian. Mexican. German, etc) <br />12. ® MARRIED WIDOWED <br />13 NAME OF SPOUSE /II wde. give maiden name/ <br />eWhite <br />f8pec1lyl Dutch <br />NEVER DIVORCED <br />MARRI <br />AM GrW <br />14a. USUAL OCCUPATION /Give kind of work dole during most <br />14b. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />of working life. even if retired/ <br />Parts Salesman <br />Auto Parts <br />Elemei � or Secondary 10 -12) college 11 -4 or 5 1 <br />N <br />�i <br />y i <br />16. FATHER -NAME FIRST MIDDLE LAST <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />v Christiaan Vredeveld <br />Janneke Voss <br />18, WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a.INFORMANT -NAME <br />(Yes. no. or unk.) (If yes give war and dates of serviced <br />' <br />Ann Vredeveld <br />No <br />z= <br />191b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />5302 N. TaIgaSS, KetdlikM, Alaska 99901 <br />20. EMBALMER - SIGNATURE 8 LICENSE NO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE 21c <br />CEMETERY OR CREMATORY NAME <br />Not embalmed <br />❑ Burial ❑ Removal <br />October 30, 2002 <br />Westlawn Crematory <br />22a. FUNERAL HOME - NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />All Faiths Funeral Home <br />191 Cremation ❑ Donation <br />Grand Island, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP( <br />2929 S. Locust St., Grand Island, Nebraska 68801 <br />23, I (ENTER ONLY ONE CAUSE PER LINE FOR la). (b1. AND (c)) I Interval between onset arxl death <br />PART <br />/ <br />I �p ef, <br />la e� C. - r -t-C <br />DUE TO. OR AS A CONSEQUENCE OF Interval between onset am seam <br />lot <br />DUE TO. OR AS A CONSEQUENCE OF <br />i Interval between onset and death <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE. WAS THERE A <br />24 AUTOPSY <br />25 WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONERS <br />11 <br />(Ages 10 -541 Yes 0 No 0 <br />Yes No <br />Yes ❑ No <br />26a <br />261. DATE OF INJURY (MO. Day. Ycl <br />260. HOUR OF INJURY <br />26d. DESCRIBE HOW IN <JRY OCCURRED <br />Accident Undetermined <br />M <br />Smcde Pending <br />26e. INJURY AT WORK <br />26f. okACEE OF INJURY - At g. farm. street. factory <br />ce <br />8 / <br />26g. LOCATION STREET OR R.F.D. NO CITY OR TOWN STATE <br />Homicide Investigation <br />Yes ❑ No ❑ <br />EATH (Mo. Day. Yr) <br />28a. DATE SIGNED (Mo.. Day Yr) <br />28b TIME OF DEATH <br />October 29, 2002 <br />N <br />�i <br />y i <br />M <br />FFEA <br />ED /Mo.. Day. Yc) <br />27c. TIME OF DEATH <br />28c. PRONOUNCED DEAD (MO.. Day, YrJ <br />28d. PRONOUNCED DEAD /HOUrI <br />01 <br />4:30 p. M <br />z= <br />M <br />of my knowledge. death occurred at the ti e, date and place and due to the <br />28e. On Me Dasis of exammaeon ando investgalbn, in my ognwn tlealh occurred at <br />° ° <br />ated. �^ <br />r 0 <br />a <br />tt1e time, date and place and due to the cause(s) stated. <br />'ISM <br />(Signature and Trial 10 / y - <br />nature and Title) ► <br />29 DID TOBACCO USE CONTRIBU 0 E DEATHS <br />.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30.b WAS CONSENT GRANTED? <br />❑ YES ❑ NO UNKNOWN <br />❑ YES <br />W 1 NO <br />❑ YES NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) IType <br />or Prinp <br />Jeffrey Kin , M.D., 7 2 9 N . Custer Avenue, <br />Grand Island, Nebraska 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo.. Day Yc) <br />7d4 ,�, <br />NOV 5 2002 <br />11 <br />