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<br />WHEN < THIS r 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 />6/28/2021
<br />LINCOLN, NEBRASKA
<br />202107190
<br />&LAI; 60,44641414
<br />Cj
<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 />21
<br />IPursuant to section 30.2413, demands for notice which may affect the estate of the deceased am filed with the county court In the county where the decedent resided at the time of death.
<br />1, DECEDENTS -NAME (First, Middle, Last, Suffix) - - - -
<br />Irene Grace Payne
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />June 20, 2021
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />5a. AGE - Last Birthday
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)'
<br />Bismarck, North Dakota
<br />(Yrs.)
<br />86
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />June 19, 1935
<br />7. SOCIAL SECURITY NUMBER
<br />508-40-0171
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 inpatient OTHER 0 Nursing Home/LTC fl Hospice Facility
<br />8b. FACILITY-NAME(1f not Institution, give street and number)
<br />5430 W. 1R Road
<br />0 ER/outpatient ® Decedent's Home
<br />0 DOA 0 Other (Specify)
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER ..
<br />5430 W. 1R Road
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g, INSIDE CITY LIMITS
<br />Q YES Cil NO
<br />105. MARITAL STATUS AT TIME OF DEATH 0 Married ❑ Never Married
<br />0 Married, but separated ® Widowed 0 Divorced 0 Unknown
<br />lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Richard John Payne
<br />11. FATHER'S -NAM£ (First, Middle, Last, Suffix)
<br />Hervey Thomas
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Lola Bryan
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk) No
<br />14a. INFORMANT•NAME
<br />Steve Payne
<br />14b. RELATIONSHIP TO DECEDENT
<br />Son
<br />15. METHOD OF DISPOSITION
<br />Burial 0 Donation
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16e. DATE(f4o., Day, Yr.)
<br />June 22, 2021
<br />cremation 0 Entombment
<br />�.h
<br />O Removal:! 0 Other (Specify)
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<br />17e, FUNERAL
<br />Curran Funeral
<br />HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Chapel, 3005 S. Locust St., 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, injuries, or complications -that directly caused the death. DO NOT enter tannins! events such as cardiac arrest,
<br />APPROXIMATE INTERVAL
<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 final ';. a) Cardiac Arrest :
<br />disease or condition resulting
<br />in
<br />onset to death
<br />Immediate
<br />death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially list conditions, if b)
<br />any, leading to the cause listed
<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 Minty 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 />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given In PART I.
<br />Hypertrophy Cardiomyopathy; Coronary Artery Disease; Factor V Leiden Clotting Disorder
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />® YES ❑ NO
<br />20. IF FEMALE:
<br />0 Not pregnant within past year
<br />Pregnant at time of death
<br />21a. MANNER OF DEATH
<br />® Natural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />i
<br />❑YES �1 NO
<br />❑; Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If pregnant within the past year
<br />❑Suicide ❑Could not be determined
<br />0 Pedestrian
<br />0 Other (Specify)
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES 0 NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home,
<br />farm, street, factory, office building,
<br />construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑YES 0 N
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f, LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />To.be::completed by
<br />MEDICAL CERTIFIER
<br />ONLY
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />Ai
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />June23,2021
<br />24b. TIME OF DEATH
<br />01:10 PM
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23e. TIME OF DEATH
<br />I g
<br />i
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />June 20, 2021
<br />24d. TIME PRONOUNCED DEAD
<br />01:40 PM
<br />3d. To the bast of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />CI
<br />B g
<br />s
<br />24s. On the basis of examination and/or investigation, In my opinion daseh oeeurrod et
<br />die -time, date and place and due to the causes) stated. (Signature end Title)
<br />Sarah Carstensen, Hall County Attorney
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ❑ NO 0 PROBABLY ® UNKNOWN
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO ❑ YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Sarah Carstensen, Hall County Attorney, 231 S.
<br />Locust, Grand Island, Nebraska, 68801
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />June 28, 2021
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