202201222 - Laserfiche WebLink

Browse

CINtneomemasia tt :<1x111tiwat.r ..;t:ta 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 DATE OF ISSUANCE 5/10/2021 LINCOLN, NEBRASKA 202201222 4r744;.4o SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR '- DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES Pursuant to section 30.2413,. demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) • .. .. �^ Chad Lynn Osburn 2. SEX Male 3. DATE OF DEAN (Mo., Day, Yr) April 30, 2021 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday sb. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Valentine, Nebraska (Yrs.) 60 MOS. DAYS HOURS MINS. March 10, 1961 7. SOCIAL SECURITY NUMBER 505-90-6853 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER ❑ Nursing Home/LTC ❑ HOsplce Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis E ERroutpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c, CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Cairo 9d. STREET AND NUMBER 606 Nubia Street 9e. APT. NO. 9f. ZIP CODE 68824 9g. INSIDECrfY<LIM TS J YES 0 NO 10a MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married ❑ Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Jolene Peters 11. FATHER'S -NAME (First, Middle, Last, Suffix) Dick Osburn 12. MOTHER'S -NAME (First, Middle, Maiden Sumams) Louise Newland 13.'EVER IN U.S. ARMED FORCES? Give dates of service H Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Jolene Osburn 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION E Burial ]Donadon o 0 16a. EMBALMER -SIGNATURE Brandon S Bachle 16b. LICENSE NO. 1537 16c. DATE(Mo., Day, Yr.) May 7, 2021 Cremation Entombment El Removal ❑:Other (Specify) 16d CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Mt. Pleasant Cemetery Cairo Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Ar fel Funerat Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -disuses, injuries, or complications -that directly caused the death. DO NOT anter 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 Tina! <: a) Blunt Force Injuries To Chest/Torso dtseaas orc4ndeion resulting in death) onset to death Minutes DUE TO, OR AS A CONSEQUENCE OF: Sequentially net conditions, H b) any, leading to the cause listed online a, onset to death DUE TO, OR ASA CONSEQUENCE OF: [OHM* UNDERLYING CAUSE C) (disease or injury that initiated onset to death'. the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? E YES ❑ NO 20. IF FEMALE: ❑: Not pregnant within pest year ©tttgPnt et tlma of death 21a. MANNER OF DEATH 0 Natural 0 Homicide Accident 0 Pending Investigation E0 21b. IF TRANSPORTATION INJURY 0 Driver/Operator Passenger 21c. WAS AN AUTOPSY PERFORMED? ' ❑ YES ENO ❑: Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑_ Unknown H pregnant within the pest year ❑Suicide ❑Could not be determined E Pedestrian 0 Other (Specify) 21 d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) Aprit 30, 2021 22b. TIME OF INJURY 08:05 PM 22c. PLACE OF INJURY -At home, Home farm, street, factory, office building, construction site, etc, (Specify) 22d. INJURY AT WORK? El YES ®No 22e. DESCRIBE HOW INJURY OCCURRED Decedent was accidentally pinned between a vehicle and residence when working on a home improvement project iv¢ milting in his rlaath 22?, LOGATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 508 Alexandria St. S, Cairo Nebraska 68824 E 1 23a. DATE OF DEATH (Mo., Day, Yr.) 6 I 24a. DATE SIGNED (Mo., Day, Yr.) May 3, 2021 24b. TIME OF DEATH 09:03 PM iE F 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 3k ss 24c. PRONOUNCED DEAD (Mo., Day, Yr.) ADM 30, 2021 24d. TIME PRONOUNCED DEAD 09:03 PM V e 0 9 I 22d. To the treat Of my knowledge, death occurred at the time, date and place end dug of cause(s)stated. d Si nature and Title ( 9 ) u E Z g w ! g § § 24e. On me basis of examination and/or investigation, in my opinion death occurred at the tans, date and place and due to the ause(s) stated. (signature and Title) Sarah Carstensen, Hall County Attorney 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? E YES 0 NO 28b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ' E YES 0 NO 27. NAME, T(T1E AND ADDRESS OF CERTIFIER (Type or Print Sarah Carstensen, Hall County Attorney, 231 S. Locust, Grand Island, Nebraska, 68801 28a. REGISTRAR'S SIGNATURE �o' 8'N� 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) May 7, 2021