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<br />WHEN TBIS OPS~ CARRIES THE RAISED SEAL OF STATE OF NEBRI4SKA IT CERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY`OP THE ORIGINAL RECORD ON FILE WITH THE;NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />10113/2023
<br />LINCOLN, NEBRASKA
<br />202305627'
<br />1544.0
<br />SARAH BOHNENKAMP T
<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 />1 PECEOENTS-NAME (First, Middle, Last, Suffix)
<br />Aritiur Franklin . Osterman
<br />4. CITY:AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Clarks, Nebraska
<br />7. SOCIAL SECUR8TY NUMBER
<br />50646.0978
<br />5a. AGE'; Last Birthday
<br />(Yrs.)
<br />0
<br />Sb. FACILITY -NAME (if that institution, give street and number)
<br />624 West 15th Street
<br />6c CI:1Y OR TOIRy f OF DEATH (Include Zip Code)
<br />Grand Island 69903
<br />9a. RESIDENCE -S'T'ATE
<br />Nebraska
<br />90.4TREET AN D! N UMBER
<br />937 5 K€nibe l St.
<br />9b. COUNTY
<br />Hall
<br />1oa MARITAL STATUS AT TIME OF DEATH RI Married 0 Never Married
<br />❑ Marled, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />t. FATHER'S -NAME fFlrst ;;. Middle, Last, Suffix)
<br />Rb Obert Eugene Osterman
<br />13. EVER IN U.& ARMED FORCES? Give dates of service If Yes.
<br />(Yes, NO, or Unk,) Yes 04/26/1959-04/15/1962
<br />15. METHOD OF DISPOSITION
<br />❑ BuriaJ J Donatlori,
<br />Cremation{ Entombment
<br />0 Removal OOther(Specify)
<br />77
<br />UNDER1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL d Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />1011 NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Voncelle Lang
<br />HOURS
<br />MINS.
<br />19 03545
<br />3. DATE OF DEATI4tMo.,
<br />March 8, 2019 <:,,:
<br />6. DATE OF BIRTH tint:, Day, Yt;
<br />October 22 1941:: ;.
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />® Other (Speclfy)Oau6htef'6..Home:
<br />[� tttltplcs FIxI1Hy ` ;
<br />8d. COUNTY OF DEATH
<br />Hall
<br />90., APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />99 (NSIDE;CITY LIMITS r;
<br />12r*to NP'
<br />1 12. MOTHERS -NAME (First,
<br />Gold le Pierce
<br />14a. INFORMANT -NAME
<br />Voncelle Osterman
<br />16a. EMBALMER -SIGNATURE
<br />Katie M. Smvdra
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION;;
<br />16b. LICENSE NO.
<br />1454
<br />Middle, Maiden Surname)'
<br />CITY /TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Hoare, 2929 S. Locust Street, Grand Island, Nebraska
<br />CAUSE OF DEATH (See instructions' and examples)
<br />18. PART I. Enter the chain of events- -diseases, injuries, or complicatlons-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 />IBfd4EDIATEcsvasiPtaa ia)METASTATIC SQUAMOUS CELL HEAD AND NECK CANCER
<br />dlsesse:or crxdatlen metdang
<br />in death/ DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequentially fist conditions, If b)
<br />any, Nadine to the cause listed..
<br />AUE TO, OR AS A CONSEQUENCE OF:
<br />Enter tit. UNDERLY1NGi CAi136 . 0)
<br />tdiseaeb: dr injury that initiated
<br />the events resulting In death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />14b. RELATIONSHIP:YO DE3EDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr,)
<br />March 13, 2/310kr
<br />8Ts4TE
<br />Nebraska
<br />174 pp Cods
<br />68801;'
<br />APPROXIMATE INTERVAL
<br />onset to d ath -:::
<br />MOTNHS
<br />onset to death
<br />IL PART 11 OTHRi SIGNIFIL"Ji NT CONDITIONS -Conditions contributing to the death butnot resulting it 1110 underlying cause given In PART L
<br />METTASTATIC:.CANCER TO LUNG
<br />2Q. JF FEMALE:
<br />'"" Notpref antwitNnpaslyemr
<br />Prugnaa a time' nt death •
<br />pragaent, but pregnant within d2 days of death
<br />Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown If pregnant mean the past year
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide:'.
<br />0 Accident ❑ Pendtng;:lnvestigation
<br />❑ Suicide 0 Could not be determined
<br />21b.'JF TRANSPORTATION INJURY
<br />RDdverlopemtor
<br />Passenger'
<br />❑. Pedestrian
<br />Other (Specify)
<br />onset to death
<br />19. WAS MEDIOAI„ EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ®NO
<br />21c. WAS AN AUTOPSY PERFORME4?
<br />❑ YES ®>NC •
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO...
<br />DATE OP INJURY (Mo„ pay, Yr,)
<br />22b. TIME OF INJURY
<br />22c. PLACEOF INJURY -Auto
<br />fatnt, street, factory, office building, construction site, eta:(Spa
<br />22d. INJURY AT WORK?
<br />❑YES NO
<br />22f Lpc'ATION OP INJ:RY'4
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />REET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />March 8, 2019
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />March 20 20:19
<br />23c. TIME OF DEATH
<br />04:00 PM
<br />23t To the bast of my knowledge, death occurred at the time, date and place
<br />end duets tae caase(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />25., 010 ❑ TOBACCO.USE CONTRIBUTE TO THE DEATH?
<br />YES ❑ O PROBABLY 0 UNKNOWN
<br />STATE 2EaCQpE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On de bans f examination and/or investigation, In my opinion death e14htthe at;
<br />the:5me, date and place and due to the cauee(a) stated. (Signature aid ilifti `
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES lit NO
<br />27, NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803'
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable H 26a Is NO OYES Q NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day,
<br />March 20, 2019
<br />
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