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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COpy CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL ~ECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />
<br />::~::::~:~TORY FOR YITAL RECOROS'I14~4l#$. ,'.'~".'.. '~.' ".'
<br />""'1,IW"_"~'rANLEJI S.. COOPER
<br />AUG 0 6 2007 200707776 ASSI$TAHT,SrATE FlEdts1t~AR'
<br />HEALTH)uiD HUMAN SERV~~
<br />
<br />LINCOLN, NEBRASKA
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERViCESFINANC. EAND. SUP~R7-'-
<br />----.---_ CERTIFlqATE qF DEATH , '-.- . WI
<br />2. sEx <, "'.
<br />Male
<br />
<br />28204
<br />
<br />1. DECEDENT'S-NAME (FirSI, Middlo, La,t.
<br />Mark Allen McCarville
<br />, "TI ^" "'" ""..,"~. " "'.;,,, "";;~ 0> "';1' .",", ""'" ;;. "'". , m.
<br />Loup City, Nebraska (Yrs) 52 MOS. DAYS
<br />
<br />7. SOCIAL SECURITY NUMBER Ba_ PLACE OF DEATH
<br />505-76-9734
<br />
<br />8u1l1.)
<br />
<br />'J, DATE OF DEATH (Mo" Day. Yr.)
<br />,J\ily 28, 2007
<br />
<br />5c. UNDER 1 DAY
<br />HOURS MINS.
<br />
<br />6. DATE OF BIRTH (Mo., Doy, Yr.)
<br />
<br />Jun 12, 1955
<br />
<br />J:!.QS1'lIAJ.:
<br />
<br />o Inpallonl
<br />
<br />QJlJE8:
<br />
<br />o Nursing Home/LTC CJ Hospica Facilily
<br />
<br />..:;,--=-...............', -- -,--- ~
<br />
<br />FACILI_TY.NAME..{1f JlOI instilulion, give ,troot end number)
<br />
<br />o ER/OulpaliOnl
<br />
<br />IX D.codent's Homo
<br />
<br />Home:
<br />
<br />3566 Hillside Drive
<br />
<br />OD.:)\
<br />
<br />o Othor (Specify)
<br />
<br />8c. CITY OR TOWN OF DEATH (Include lip Code)
<br />Grand Island
<br />
<br />68803
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<br />Bd. COUNTY OF DEATH
<br />Hall
<br />
<br />9b. COUNTY
<br />Hall
<br />
<br />
<br />9d. STREET AND NUMBER' ge. APT:NO~P CODE -~iDECiTYi:"IMITS
<br />3566 Hillside Drive, ~ 68803 ~ YES 0 NO
<br />
<br />,,,. ...,,~ mw,^n,", 0> "^~ ",;;;;;;0;;;,,, ,,,"~ J" '^"' 0> '''"'' ",,' "~"Co. ",. '"'"' "",.. ".. ~q" ~-;-- -
<br />
<br />o Mar".d, bUI separal.d 0 Wldow.d 0 Dlvorcod 0 Unknown Diane Stobbe
<br />
<br />--~ft~ _-----.....
<br />Middle, Lasl, Suffix) 12. MOTHER'S-NAME (Firsl, Middle, Maiden Surname)
<br />McCarville Clara Placzek
<br />
<br />, 1. FATHER'S.NAME (FirSI,
<br />Edward
<br />
<br />13. EVER IN U.S. ARMED FORCES? Give dales of s.rvlce if y.s. 14a.INFORMANT-NAME
<br />(Yes, no, orunk.) No Diane McCarville
<br />
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />
<br />I Be. DATE (Mo" Day, Yr. )
<br />July 31, 200..1_
<br />
<br />STATE
<br />
<br />Grand Island, NE.
<br />
<br />PART I. Enter the chain of evp.nl!l--diseases, injuries, or complications--tha1 directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />r.spiratory arr.st, or venlricular fibrilla liOn withoUI showing Ihe eliology. 00 NOT ABBREVIATE. Enler only one cause on a line. Add additionelllnas if necessary.
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />IMMEDIATE CAUSE (Fln.1
<br />dl_orcondUIQn resulUng
<br />Indoath)
<br />
<br />(a)
<br />
<br />/ht! ~t;~/.(~
<br />
<br />ICA s:J
<br />
<br />(417(flr
<br />
<br />ons.t to dealh
<br />
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />
<br />on! 'tiP (J r
<br />onset 10 61th
<br />
<br />Sequentially list condltlQns,lf (b)
<br />any,leadingtQthecausellsted ----mJE TO, OR AS A CONSEQUENCE OF: .--'-.-'-'"
<br />on line I.
<br />Enterth. UNDERLYING CAUSE
<br />(di....e or Inlury that Inltlat.d (c)
<br />th8events reaultlng In death) DUE TO, OR AS A c"ONSEQUEN~'--"--_._"~
<br />lASI' ___
<br />
<br />onset 10 d.ath
<br />
<br />..~~.,,----------..,.~
<br />onsel to doath
<br />
<br />(d)
<br />
<br />PART II. OTHER SIGNIFICANT CONDITIONS.Condlllons contribUling to Ihe death but not resulting in Ihe und.rlylng c.us. given in PART I.
<br />IJ) .vt
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />DYES lU.-N0
<br />
<br />20. IF FEMALE:
<br />Q Not pregnant within past year
<br />o Pregnant alllme 01 dealh
<br />o Not pregnane but pregnant wilhln 42 days of dealh
<br />Cl NOI pr.gnanl, but pregnanl43 days to 1 year before dealh
<br />o Unknown if pregnant within the past year
<br />
<br />21a. MA~ER OF DEATH
<br />B"Natural 0 Homicid.
<br />
<br />o AccidenlO P.nding Inv.stigation
<br />o Suicide 0 Could nol be d.lermlned
<br />
<br />21 b.IFTRANSPORTATION INJURY
<br />o Drlver/Op.rator
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<br />o passeng.r
<br />
<br />CJ Pedestrian
<br />
<br />o Olher (Specify)
<br />
<br />21 c. WAS AN AUTOPSY PERFORMED?
<br />DYE S I:J1(c)"
<br />
<br />....22.. DATE OF INJURY(MO.. Day, Yr.)
<br />
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE CAUSE OF DEATH?
<br />DYES U NO
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<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, farm, streel, faclory, of tic. building, conslruction silo, .Ic. (Specify)
<br />m
<br />
<br />-~--~- --- ---.~-~-------------
<br />22d INJURY AT WORK? 22. DESCRIBE HOW INJURY OCCURRED
<br />o YE3 0 NO
<br />--.- --~------~--------~~~- -
<br />22f. LOCATION OF INJURY. STREET & NUMBER, APT. NO. CITY/TOWN STPJE ZIP CODE
<br />
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />J..dj ZR, 'Cao7
<br />.,~,,'--- --~-'.~--.
<br />23b. DATE SIGNED (Mo" Day, Yr.) 23c. TIME OF DEATH
<br />7" )@ ~ 2-007& ~.S".4m
<br />
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />
<br />24b. TIME OF DEATH
<br />
<br />:z>
<br />~~!M
<br />11;;;15
<br />!H~
<br />e."' t z
<br />8ffizO
<br />"z=>
<br />.aoo
<br />p.~t.)
<br />80
<br />
<br />""-"""~--~ ~'~"~---"''''-''
<br />
<br />m
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<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />m
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<br />24e. On the basis of examination and/or Investigation, in my opinion death occurred at
<br />Iholime, dalo and place and due to Ihe caus.(s) slaled. (Signature and Tit)e) ...
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />
<br />~. 0 NO ". 0 PROBABLY 0 UNKNOWN 0 YES.. ~O
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER '(PHYSICIAN~CORONER'S PHYSICIAN OR couNit!i.TToFiNEYl (Type or-~."
<br />Gar Settje M.D. 2116 w. Faidle Ave., Grand Island,
<br />
<br />26b. WAS CONSENT GRANTED?
<br />
<br />Not Applicable if 26a is NO
<br />
<br />o YES~_
<br />
<br />
<br />NE. 68803
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<br />2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />
<br />AUG
<br />
<br />1 2007
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