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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS *z
<br />201906091 ASSIS ANT STATE REGISTRAR
<br />RUSSELL FOSLER
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DATE OF ISSUANCE
<br />8f3012019
<br />LINCOLN, NEBRASKA
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Clarence G Ostermeier
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />505-22-8433
<br />3 bb. FACILITY -NAME (if not institution, give street and number)
<br />CHI Health St. Francis
<br />'C
<br />Sc. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />4701 W. Old Potash Hwy
<br />Sb. COUNTY
<br />Hall
<br />5a AGE . Last Birthday
<br />(Yrs.)
<br />97
<br />Sb. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />;E � %i3A� � iii3i�,l �t�iit�$."
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 24, 2019
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL El Inpatient
<br />ER/Outpatient
<br />DOA
<br />10a. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Never Married
<br />Married, but separated E Widowed 0 Divorced ❑ Unknown
<br />11. FATHER'S.NAME (First, Middle, Last, Suffix)
<br />Ernest Ostermeier
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, orUnk.) No
<br />15. METHOD OF DISPOSITION
<br />❑'Burial ❑ Donation
<br />E Cremation 0 Entombment
<br />Q Removal :' © Other (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr )
<br />February 24, 1922
<br />OTHER 0 Nursing Home/LTC
<br />n Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />0 Hospice Facility
<br />9g. INSIDE CITY LIMITS
<br />IE YES ❑ NO
<br />10b. NAME OF SPOUSE (First, Middle, List, Suffix) If wife, give maiden name
<br />Velma Poizel
<br />112. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />lMarie Burgholz
<br />14a. INFORMANT -NAME
<br />Tom Ostermeier
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
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<br />0
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<br />18. PART I. Enter the chain a -events- disuses, injuries, or complications -that directly caused the death. DO NOT elttertenninal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a One. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home. 2929 S. Locust Street. Grand Island. Nebraska
<br />I disease or condition resulting
<br />W
<br />a
<br />2
<br />S
<br />13
<br />tb
<br />c0
<br />z
<br />15
<br />In death)
<br />Sequentially list conditions, if
<br />any, leading to the reuse listed
<br />on lint al_.. _..
<br />Enter the UNDERLYING CAUSE
<br />0d1seese or injuryinitiated.
<br />the sxents resulting in death)
<br />tAST
<br />CAUSE OF DEATH (See instructions and examples)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)Acute Myocardial Infarction
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />14b. RELATIONSHIP.: TO DECEDENT
<br />Son
<br />16c. DATE (Mo, Day, Yr.)
<br />August 27, 2019
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />20.1F FEMALE:
<br />❑-Not pregnant within past year
<br />❑Pregnant at time of death
<br />❑ Not pregnant: but pregnant
<br />Not
<br />within 42 days of death
<br />nt: bin pregnant 43 days to 1 year before death
<br />©
<br />unknown
<br />M pngnets withinthe past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d. INJURY AT WORK?
<br />DYES 0 N
<br />21a. MANNER OF DEATH
<br />E Natural 0 Roadside
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />2tb. IF TRANSPORTATION
<br />❑ Driver/Operator
<br />0 Passenger
<br />❑..Pedestrian
<br />:❑
<br />Other (SPecify)
<br />INJURY
<br />APPROXIMATE INTERVAL,
<br />onset to death
<br />4 a4nnr�
<br />onset to death::
<br />1 Month
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES E NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES E NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES 0 N
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />S
<br />c
<br />3
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<br />August 24, 201B
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />A w ust 26 2019
<br />H.
<br />23c. TIME OF DEATH
<br />05:47 PM
<br />3d. To the best of my knowledge, death occurred at the t
<br />and due to the cause(s) stated. (Signature and Title)
<br />Richard Fruehlinq, MD
<br />25. DID TOBACCO UST» CONTRIBUTE TO THE DEATH?
<br />, date and place
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr. 24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated. (Signature and Title)
<br />❑ YES E NO 0 PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br />0 YES E NO Not Applicable if 26a Is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Richard Fruehlin9, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />8a.'REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />August 27, 2019
<br />
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