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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 8/30/2018 LINCOLN, NEBRASKA 20180747/ RUSSELL FOSLER INTERIM ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are flied 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 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Rawlins, Wyoming (Yrs.) 88 MOS. DAYS HOURS MINS. July 23, 1930 7. SOCIAL SECURITY NUMBER 506-28-9674 8a. PLACE OF DEATh HOSPITAL E Inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (if not Institution, give street and number) CHI Health St. Francis 0 ERfOutpatient ❑ 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 Grand Island 9d. STREET AND NUMBER 404 Woodland Drive 9e. APT. NO. 408 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS ® 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 Patricia A ' McMinamen 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred L Kirschbaum. 12. MOTHER'S -NAME (First, Middle, Maiden Surname) 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 ®Donation 16a. EMBALMER -SIGNATURE Benjamin Hall 16b. LICENSE NO. 1305 16c. DATE (MO., Day, Yr.) August 16, 2018 ❑ Cremation 0 Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Nebraska Anatomical Board Omaha Nebraska 17a, FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Nebraska Anatomical Board 986395 Nebraska Medical Center. Omaha. Nebraska 17b, Zip Code 68198-6395 CAUSE OF DEATH (See instructions and examples) tit. PART 1. Enter tits chain of events --diseases, injuries, or complications -that directly caused th8. death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventrifular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Cerebral Hemorrhage - Subdural, Intraparenchymal And Intraventricular disease or condition resulting onset to death Hours in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) any, leading to the: cause listed line a. onset to death on DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) (disease or injury that initiated onset to death the evemsresuutng in death) s DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset t0 death 18. PART II. OTHER COPD, Dementia SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting Of The Frontotemporal Variety, AAA Without Rupture, Hypertension Hypothyroid in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ENO- 20. IF FEMALE: ;. ❑ Not pregnant within 0 Pregnant at time of past year death❑ 21a. MANNER OF DEATH E Natural 0 Homicide ❑ Accident ❑ Pending Investigation 21b, IF TRANSPORTATION INJURY ❑ Driver/Operator Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year El SuicideCouldnot be determined ❑ ❑ Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? 0 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 N 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREETS NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) AuquSt 16, 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 23c. TIME OF DEATH 03:08 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. 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 cause(s) stated. (Signature and Title) 25, DID TOBACCO USE CONTRIBUTE TO THE DEATH? YES 0 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE _DOIJA T,Ci2 BE!N CONSIDERED? E YES 0 NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES E NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE J-~ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr) August 22, 2018