To be completed/verified by: FUNERAL DIRECTOR _ I
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />Charles Ivan Herbst
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />November 1, 2015
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Lincoln, Nebraska
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />89
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />October 8, 1926
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />7. SOCIAL SECURITY NUMBER
<br />506 -22 -0171
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility
<br />❑ ER/Outpatient ❑ Decedent's Home
<br />❑ DOA ❑ 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 />1103 W Koenig Street
<br />Se. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Alice Mae Kissinger
<br />11. FATHER'S•NAME (First, Middle, Last, Suffix)
<br />Charles Herbst
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Iva Unknown
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes Dates Unknown
<br />14a. INFORMANT -NAME
<br />Alice Mae Herbst
<br />1413. RELATIONSHIP TO DECEDENT
<br />Wife
<br />15. METHOD OF DISPOSITION
<br />❑ Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑ Removal ❑ Other (Specify)
<br />16a. EMBALMER- SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />November 3, 2015
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />Central Nebraska Cremation Services Gibbon Nebraska
<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 />17b. Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />To be completed by: CERTIFIER
<br />18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ; 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. 1
<br />IMMEDIATE CAUSE: : onset to death
<br />IMMEDIATE CAUSE (Final a) Failure To Thrive 1 2 Weeks
<br />1
<br />disease or condition resulting 1
<br />in death) DUE TO, OR AS A CONSEQUENCE OF: l onset to death
<br />Sequentially list conditions, if b) Dementia 1 Chronic
<br />any, leading to the cause listed I
<br />I
<br />line
<br />on a. DUE TO, OR AS A CONSEQUENCE OF: i onset to death
<br />Enter the UNDERLYING CAUSE c) I
<br />(disease or injury that initiated ;
<br />the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br />LAST d) I
<br />1
<br />1
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Renal Mass /renal Failure
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES ® NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑Pending Investigation
<br />❑ Suicide ❑ could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES Ea NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, 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 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />W
<br />r
<br />o u z
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 1, 2015
<br />; s Z
<br />1 c k Y
<br />4E y! O
<br />w i
<br />p
<br />U
<br />,2 o 8
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />November 2, 2015
<br />23c. TIME OF DEATH
<br />08:45 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24d. TIME PRONOUNCED DEAD
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />2 f2 and due to the causes) stated. (Signature and Title)
<br />M Ryan D. Crouch, DO
<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 cau e(s) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 2 6a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES ® NO ❑ PROBABLY ❑ UNKNOWN ❑ YES ® NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Ryan D. Crouch, DO, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br />128a. REGISTRAR'S SIGNATURE A - �
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />November 4, 2015
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKKA'DEP,4MTMENT Of HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL, RECORDS.
<br />DATE OF ISSUANCE
<br />11/09/2015
<br />LINCOLN, NEBRASKA
<br />STATE OF NEBRASKA
<br />201507898
<br />STANLEY S.. CODPER
<br />ASSISTANT,STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICE'
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />15 06389
<br />
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