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<br />STATE OF NEBRASKA
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<br />WHEN THIS` COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH T HE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN.SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATt OFISSUANCE
<br />11 t/2t41'
<br />LINCOLN, NEBRASKA
<br />/di tc,
<br />o`_
<br />a
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF F NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. o caDENT'S-NAME ;(First, Middle, Last, Suffix)
<br />Norman Jolt K(Irschbaum
<br />4. CITY AND STATE OR:TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Madison, Nebraska
<br />8C+CIAL SECURITY NUMBER
<br />506:44-2249
<br />6a, AGE - LatiA Birthday.
<br />(Yrs.)
<br />84
<br />8b. FACILITY -NAME Of not Institution, give street and number)
<br />CHI Health St. Francis
<br />5b: UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />8a. PLACE OP DEATH
<br />HOSPITAL 120 Inpatient
<br />DAYS
<br />0 ER/Ou patient
<br />❑ DOA
<br />Bc. Ct • OR TOWN OF DEATH (Include Zip Code)
<br />€arid Island 68803
<br />e 9a. RESIDENCE -STATE
<br />Nebraska
<br />d. STREET ANC/NUMBER
<br />4135 Driftwood Drive
<br />9b. COUNTY
<br />Hall
<br />10X' NIARITAL;STATUS AT TIME OF DEATH ® Married ❑ Never Married
<br />0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S•AiAME (First, Middle,
<br />Charles Kirschbaum
<br />13. EWER IN 11.$,.. ARMED FORCES? Give
<br />3 (Yes, No, or Unk) NO
<br />15. METHOD OF DISPOSITION
<br />6 i Burial ❑ Donil)on
<br />Cremation ❑ Entombment
<br />Removal ❑Other (Specify)
<br />Last,
<br />Suffix)
<br />dates of service if Yes.
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH iiiWi Daj✓ YI'4
<br />November
<br />6. DATE OF'BIRT14(Mo bay,.Vr,)
<br />March 2‘193.7.:,...... . .
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />Hospice Facility
<br />Sg INS#DE OI LYMM1Ta
<br />[3111146.:1
<br />19b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give maiden tine
<br />Madeleine Cooper
<br />• 12. MOTHER'B-NAME (First, Middle, Maiden Surname
<br />• Ellen . Elitsibeth Collins
<br />14a. INFORMANT -NAME
<br />Madeleine Kirschbaum
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />1Sd. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a. ":FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State),;
<br />Apfel Purirai (-#Orris, 1123 W. 2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />CAUSE OF DEATH' (See harp tone and exa
<br />CITY / TOWN
<br />Gibbon
<br />14b. RELATIONSHIP TO CEO
<br />Spouse
<br />16c. DATE (Mo„
<br />November 2021
<br />STAT
<br />Nebraska
<br />moles)
<br />18. PART!. Enter the chain of events. -diseases, injuries, or compilcatlons4hat 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 />IMMEDIATE CAUSE (Etna) a) acute systolic CHF
<br />disease or Condit on relUntidit
<br />In dean!);::..: ..
<br />Sequentially list conditions, If
<br />any„feeding to the eaves listed
<br />EntertheUNDERi ING CAt/SE
<br />(disease dr Injurythat.,tlltlated
<br />are events resulting in death)
<br />LAST...
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)ischemic cardiomyopathy
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) coronary artery disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />i8. ;PAE1 It OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />acute k)dneraniuly, ci rdiogenic shock, atrial fibrillation, morbid obesity.diabetesmellitus type 2•
<br />IF. FEMALE;
<br />slot pregnant witidn past year
<br />O>
<br />Pregnant at Brre of death::
<br />❑ NRC pregnant,, but pregnam within 42 days of death
<br />❑ ;Nat pregnant, but pregnant 48 ddays to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />•22a. iDATEOF'.INJURY
<br />g 22d. INJURY AT WORK?
<br />❑YES s❑ NO
<br />22L U. CATLON Of lPJUr
<br />21a. MANNER OF DEATH
<br />IE Natural ❑ HonilCWe
<br />El Accident ❑ Paiute) not investigati
<br />be determined
<br />on
<br />0 Suicide 0 Could
<br />22b. TIME OF INJURY
<br />22c. PLACE OF I
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />STREET & NUMBER, APT.NO.
<br />23a. DATE OP DEATH (Mo., Day, Yr.)
<br />November 4, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />Nt)t(ember:4.
<br />3021
<br />tilt), TO the beat of triy knowledge,' death occurred at the time, date and place
<br />Sod due to the caute(s): stated. (Signature and Tine)
<br />Jay C. Anderson, MD
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />03:30 AM
<br />URY At ho
<br />21b. IF TRANSPORTATION INJURY
<br />Driver/Operator
<br />Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />onsbtto death
<br />Years
<br />on tode(0h
<br />Years
<br />onset death
<br />19. WASM D;IIGALEXAM R..' ::
<br />OR CORONIO9130NTACTSOI
<br />❑ YES ®NO;
<br />21c. WAS.AN AUTOEsyPE ED?
<br />❑ YEs I.
<br />21d. WERE AUTOPSY'FINt41NGS A{(J II ABLt3
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ No
<br />e, farm, street, factory, office building, construction eI
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />ata (t)
<br />Z(P'aEODE ;
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAQ
<br />the basis of examination andlor Investigation, in my opinion attr egie
<br />time, date and place and due to the causes) stated. (Signabne attt rile)
<br />25. DI..TOBACCQUSE CONTRIBUTE TO THE DEATH?
<br />0 YES NO 0 PROBABLY 0 UNKNOWN
<br />27.NAME,'ti AND ADDRESS OF CERTIFIER (Type or Print
<br />JaY C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a.' REGISTRAR'S SIGNATURE
<br />L
<br />26a. HAS ORGAN
<br />❑ YES
<br />OR TISSUE DONATION peen CONSIDERED?
<br />NO
<br />at:
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO [� YES
<br />28b. DATE FILED BY REGIS
<br />November 7, 2021
<br />(Mo., Day, Yr.)
<br />
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