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STATE OF NEBRASKA �'{131 tf 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 de '2 019 0 3 5 5 1 ASSISTANT STATE REGISTRAR RUSSELL FSLER DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH DATE OF ISSUANCE 2/26/2019 LINCOLN, NEBRASKA Amended 19 01298 Pursuant to section 30-2413, demands for notice which may affect the estate of the deceasedare filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Calvin Howard Owen 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) January 25, 2019 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Se. AGE • Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Moi, Day, Yr.) • Elm Creek,' Nebraska t'ffs.) 88 MOS.DAYS I HOURS MINS. I May 2, 1930 7. SOCIAL SECURITY NUMBER 508-30-4964 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) Providence Place of Hastings 0 ER/Outpatient 0 Decedent's Home 0 DOA E Other (SpecifyA.SSISTED LIVING 8c. CITY OR TOWN OF DEATH (Include Zip Code) Hastings 68901 , 8d. COUNTY OF DEATH Adams 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Doniphan 9d. STREET AND NUMBER 312 Campbell Avenue 9e. APT. NO. 9f. ZIP CODE 68832 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS. AT TIME OF DEATH ❑ Married 0 Never Married ❑ Married, but separated ® Widowed 0 Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Elizabeth Louise Siebke 11. FATHER'S -NAME (First, Middle, Last, Suffix) Howard Jay Owen 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Murna Elinore Shubert 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or kink.) Yes 09/16/1948-05/09/1952 14a. INFORMANT -NAME Deb Thompson 14b. RELATIONSHIP TO DECEDENT Daughter 15. METHOD OF DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE John Butler 16b. LICENSE NO. 1210 16c. DATE (Mo., Day, Yr.) January 30, 2019 ❑ Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Elm Creek Cemetery Elm Creek Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Horner Lieske McBride & Kuhl Funeral and Cremation. 2421 Avenue A. Box 777. Kearney. Nebraska 17b. Zip Code 68848 CA,l_!SE CF 11.EATt1 IS_cc ham ct',cnc «:514. Cxcmplos' 18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL 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) Cardiopulmonary Arrest disease or condition resulting onset to death Seconds In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death Sequentially -list conditions, if b)Chronic Obstructive Pulmonary Disease Years any, leading to the cause tasted line on a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE C) (disease of injury that initiated onset to death the events resuhingin death) DUE TO, OR AS A CONSEQUENCE OF: LAST:'. d) onset to death 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Lung Cancer, Diastolic Congestive Heart Failure, Diabetes Mellitus Type 2, Coronary Artery Disease, Paroxysmal Atrial Fibrillation 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? 0 YES ® NO 20. If FEMALE: 0 Not pregnant within past year Pregnant at time of death ID❑ 21a. MANNER OF DEATH - ® Natural 0 Homicide Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑YES ®NO 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant; but pregnant 43 days to 1 year before death 0 Unknown if pregnant w4tt!in the past year ❑ Suicide 0 court not be determined 0 Pedestrian 0 Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 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? ❑YES 0 N 22e. DESCRIBE HOW INJURY OCCURRED I?2f• LOCATION OF INJURY - STREET R NI IMRER. APT NO Cl-rvny NN STATE 71P conE rnpreted by.'. CERTIFIER::.. NLY 23a. DATE OF DEATH (Mo., Day, Yr.) January 25, 2019 To be competed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) 123c. TIME OF DEATH January 30, 2019 I 07:31 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 3d. To the and 12 Douglas best of my knowledge, death occurred at the time, date and place due to the cause(s) stated. (Signature and Title) Hentzen, MD 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 0 YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Douglas Hentzen, MD, 2115 N Kansas Avenue Hastings, Nebraska, 68901 y 28a. REGISTRAR'S SIGNATUREC-------------- --------- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) February 1, 2019 Amended 2/26/2019 Item 7 Social Security Number, 9b County Of Residence, 23c Time Of Death