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<br />STATE OF NEBRASKA
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />David Charles McCarthy
<br />4, CI AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />7. 5 C - .c;:;: iu/iRER
<br />505- 42.3730
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<br />Sb, FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health.St. Francis
<br />❑ ER/Outpatient
<br />❑ DOA
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9d. STREET AND`NUMBER
<br />1812 W. John
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br />13. EVER iN U.S.: ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk,) Yes ;,:02/06/1961- 02/05/1965
<br />'15. METHOD OF I5ISPOSITIQN
<br />❑ Burial ® Donation
<br />❑ Cremation 0 Entombment
<br />El Removal 0 Other (Specify)
<br />16a. EMBALMER - SIGNATURE
<br />Benjamin Hall
<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 />9e. APT. NO.
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />9f. ZIP CODE
<br />68801
<br />9c. CITY OR TOWN
<br />Grand Island
<br />8d. COUNTY OF DEATH
<br />Hall
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Judith _L McClintock
<br />11. FATHER'S - NAME (First, Middle, Last, Suffix)
<br />John McCarthy
<br />42. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Pearl Copple
<br />14a. INFORMANT-NAME ..
<br />Judith L McCarthy'
<br />16b LICENSE NO.
<br />1305
<br />9g. INSIDE CITY LIMITS
<br />® YES ❑ NO
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, ?'Yr.):;
<br />October 23, 2017
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Nebraska Anatomical Board
<br />CITY /TOWN
<br />Omaha
<br />STATE
<br />Nebraska;
<br />17b. Zip: Code
<br />68801
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<br />PART I. Enter the al of events- - diseases, injuries, 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. DC NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEOIA " CAUSE:
<br />IMMEDIATE CAUSE (Final a) Large Intracranial Hemorrhage
<br />disease or condition resulting
<br />in death)
<br />Sequentially list conditions, if
<br />any, loading to the cause NSW»
<br />on line a.
<br />Enter the UNDERLYING CAUSE
<br />/disease o in)ury Initiated:;:
<br />tare events.esbhing In death)
<br />tAST'
<br />0
<br />WHEN THIS !I "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 />10/31/2017
<br />LINCOLN, NEBRASKA
<br />URY ATWQRIt?
<br />STATE OF NEBRASKA - DEPARTMENT, OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />13) Unknown
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />O. )FFEMALE:
<br />wi
<br />❑ Not pregnant thin past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregrtant,;bet pregnant:44 days to 1 year before death
<br />sown if piegnantwithin the past year
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF IN JURY STREET & NUME'ER, APT.NO.
<br />a. DATE QF OEATH (Mo., Day, Yr.)
<br />O 20 2017
<br />Y 23b. DATE SIGNED (M Day, Yr.) 23c. TIME OF DEATH
<br />o October 26, 2017 05:00 PM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the cause(s) stated. (Signature and Title)
<br />Douglas Her}aek, MD
<br />5. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />201805307
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />79
<br />8a, REGi$TRAR`$ SIGNATURE /
<br />Sb. UNDER 1 YEAR
<br />MOS.
<br />LACE 07r DEATH
<br />nSRi r at,I •npat:7,,t
<br />DAYS
<br />. i: l i . E Cr r " H e "1- t,C ;3::and cncarnpIES
<br />APPROMMATEsINTERVAL
<br />c,:iiet to death
<br />Days
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Homicide
<br />❑ Accident ❑ Pending Investigation
<br />❑ Suicide ❑ Could lint be determined
<br />22a. DATE OF INJURY (Mo., Day, Yr.) I i i U
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />CITYIIJN
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />HOURS
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver /Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />0 Other ..(Specify)
<br />STATE
<br />T 24a. (;"4,:`,.:
<br />SIG'ZD N (NIG., Ca„ 'f r.;
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<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />26a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDERED?
<br />YES NO PROBABLY UNKNOWN ❑ YES ❑ NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Dou Ias Herbek, MD, 2444 W. Faidley Avenue, Grand Island, Nebraska, 68803
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<br />STANLEY S. t,"OOPER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT HEALTH AND
<br />HUMAN SERVICES
<br />MINS.
<br />. DATE OF DEATH (Mo., Day, Yr.)
<br />October 20, 2017
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />June 19, 1938
<br />OTHER ❑ Nursing Home /LTC C1 Hospice Facility
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES El NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES . ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEAATH ?;;
<br />❑ YES ❑ NO
<br />24b. TIME OF DEATH
<br />ZIP CODE
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination andlor investigation, in my opinion death occurred at
<br />the time, date and place and due to the cause(s) stated, (Signature and Title)
<br />28b. DATE FILED BY REGISTRAR (Ma.,:Day, Yr)
<br />October 26, 2017
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ❑ YES ❑ NO
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