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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
<br />DATE OF ISSUANCE
<br />5/10/2021
<br />LINCOLN, NEBRASKA
<br />20210426]
<br />Wa: et OE_
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />21 05993
<br />1. DECEDENT'S -NAME (First, Middle, Laat, Suffix)
<br />Chad Lynn Osbum
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Valentine, Nebraska
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />April 30, 2021
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />60
<br />Sb. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />8. DATE OF BIRTH (Mo., Day. Yr.) <I
<br />7, SOCIAL SECURITY NUMBER
<br />505-90-6853
<br />8b. FACILITY -NAME: (If not Institution, give street and number)
<br />CHI Health St, Francis
<br />8c.CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Is(and 68803
<br />9a. RESIDENCESTATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />® ER/Outpatient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Cairo
<br />March 10;,1961
<br />OTHER ❑ Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />ad. STREET AND NUMBER
<br />606 Nubia! Street
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68824
<br />9g. INSIDE CITY LIMITS
<br />Et YES D NO
<br />10a. MARITAL STATUS AT TIME OF DEATH E Marded 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced ❑ Unknown
<br />1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Jolene Peters
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Dick Osburn
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Louise Newland
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />14a. INFORMANT -NAME
<br />Jolene Osburn
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />0 Cremation 0 Entombment
<br />0 Removal ❑ Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />18b. LICENSE NO.
<br />1537
<br />16c. DATE (Mo., Day, Yr.)
<br />May 7, 2021
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Mt. Pleasant Cemetery Cairo
<br />STATE
<br />Nebraska
<br />170, FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801'
<br />CAUSE OF DEATH (See Instructions and examples)
<br />18. PART I. Enter the chain of events- diseases, Injures, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE(Rnal s a) Blunt Force Injuries To Chest/Torso
<br />disease or condition resulting
<br />In death)
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Minutes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading tothe causelisted
<br />on line a.
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />(disease or injury that initiated
<br />onset to death
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />onset to death
<br />1S. PART II.OTHER SIOMFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES ❑ NO
<br />20. IF FEMALE:.
<br />❑'Not pregnant within past: year
<br />Pregnant et time of death
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />0 Unknown If pregnant within the past year
<br />21a. MANNER OF DEATH
<br />0 Natural ❑ Homicide
<br />E Accident 0 Pending Investigation
<br />❑ Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />E Pedestrian
<br />❑ Other (specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES &I NO
<br />21d. WERE AUTOPSY:. FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑NO
<br />22a. DATE OF INJURY (Ma, Day, Yr.)
<br />April 30, 2021
<br />22b. TIME OF INJURY
<br />08:05 PM
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, (Specify) ;!
<br />Home
<br />22d. INJURY AT WORK?
<br />DYES ®NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Decedent was accidentally pinned between a vehicle and residence when working on a home improvement project
<br />remilting in hic rlmnth
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO.
<br />508 Nexgndria St S, Cairo
<br />C
<br />o
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />CITY/TOWN
<br />STATE
<br />Nebraska
<br />ZIP CODE
<br />68824
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />29d. To the best of my knowledge, death occurred at the time, date and place
<br />and due tote- cause(s) stated. (Signature and Title)
<br />z
<br />�e
<br />83
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />May 3, 2021
<br />24b. TIME OF DEATH
<br />09:03 PM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />April 30, 2021
<br />24d. TIME PRONOUNCED DEAD
<br />09:03 PM
<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 easels) stated. (Signature and Tale):;
<br />Sarah Carstensen, Hall County Attorney
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES j NO ;'❑ PROBABLY 0 UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />E YES ❑ NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ® YES'
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sarah Carstensen, Hall County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />May 7, 2021
<br />CD
<br />CD
<br />I)
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