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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) James Leonard Kirschbaum 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) August 15, 2018 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Rawlins, Wyoming 5a. AGE - Last Birthday (Yrs.) 88 , 5b, UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) July 23, 1930 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 506 -28 -9674 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER ❑ Nursing Home /LTC ❑ Hospice Facility 8b. FACILITY -NAME (If not institution, give street and number) CHI Health St. Francis ❑ ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE COUNTY Nebraska 19b. Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 404 Woodland Drive 9e. APT. NO. 408 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married ❑Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Patricia A McMinamen 11. FATHER'S -NAME, (First, Middle, Last, Suffix) Fred L Kirschbaum 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Margorie B Horn 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 07/04/1952- 04/01/1954 14a. INFORMANT -NAME Patricia A Kirschbaum 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION Burial t] Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Beniamin Hall 16b. LICENSE NO. 1305 16c. DATE (Mo., Day, Yr.) August 16, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Nebraska Anatomical Board Omaha Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Nebraska Anatomical Board. 986395 Nebraska Medical Center. Omaha. Nebraska 17b. Zip Code 68198 -6395 CAUSE OF DEAT See i stru Lions and exam .Ies 13. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT eater terminal events such as cardiac arrest, APPROXIMATE INTERVAL :. onset to death Hours respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause MI a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cerebral Hemorrhage - Subdural, Intraparenchymal And Intraventricular disease or condition resulting in death) .to death DUE TO, OR AS A CONSEQUENCE OF: onset Sequentially list conditions, if b) any, leading to the cause listed line a. on DUE TO, OR AS A CONSEQUENCE OF: onset to death Enter the UNDERLYING CAUSE c) (disease or injury that initiated the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death LAST d) - 8. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but tot resulting in the underlying cause given in PART I. COPD, Dementia Of The Frontotemporal Variety, AAA Without Rupture, Hypertension, Hypothyroid 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES < ® NO 20.1F FEMALE: = 0 Not pregnant within' past year ❑ Pregnant death at time of dth ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year 21a. MANNER OF DEATH El Natural 0 Homicide ❑ Accident ❑ Pending Investigation 0 Suicide 0 Could not be determined 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES El NO 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑ YES 0 NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) August 15, 2018 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a, DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b, DATE SIGNED (Mo., Day, Yr.) August 22, 2018 mpleted CERTIFI NLY w P D a c =v CI -t C m N E 0 N m N OD 1 O 3 O 23c. TIME OF DEATH 03:08 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 12 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Kimberly A. Mickels, MD 24e. On the basis of examination and /or Investigation, in my opinion death occurred at the time, date and place and due to the causes) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? Ed YES ❑ NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? El YES ❑ NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ® NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 I 28a. REGISTRAR'S SIGNATURE �'' 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) August 22, 2018 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 8/22/2018 LINCOLN, NEBRASKA RUSSELL FOSLER DEPARTMENT HEALTH AND INTERIM ASSISTANT STATE REGISTRAR HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH