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<br />STATE OF NEBRASKA
<br />� �����F �
<br />WHEIV THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HPALTl�VD U 11N `5� VIC�'S, IT CERTIFIES
<br />THE BELOW r0 BE A 7RUE COPY OF THE ORIGINAL RECORD ON FILE WITH TFIE NEBRA�K�A ,(�'E�A��MI IV�` Q�" UiEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE tEGAL DEPOSITORY FOR �111T�. RP �.��'
<br />� � . ���� �'. � y � ,
<br />DATE Of tSSUANCE �/�/��q�� �� .
<br />4 ,a ��
<br />„� ,
<br />S�At�.�YS,��C �PE., r
<br />03/22/2011 2 0�.10 4 2 9 3 � A��T�N������Q ��R: �,�.
<br />D��A�t��".MENT �F HPALTH ARJL,� � ; -
<br />LINCOLN NEBRASKA HIS��IA�Is5�1��11ICE5` ;.. -�'
<br />' STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND H�MAN SERVI��S c`� �'�� �� ���� �
<br />CERTIFICATE OF DEATH - � - ` _ � � � s � ,�,� , �',' y �'�� 10T,03335
<br />'. DECEDENTS-NAME (Flrst, Middle, Last, Sufflx) ' 2. SDC, -°� a 3. PATf QF �'ATH (Mo:; Day, Yr.
<br />o :. ti. i.�� . �
<br />Mark Arthur Hirsch Male' No°vember:l5, 2010
<br />I. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE - Last Blrthday b. UNDER 1 YEAR 5c. UNpER 1 DAY_ 6. DATE OF BIRTH (Mo„ Day, Yr.)
<br />(YBd MOS. DAYS HOURS MINS.
<br />No�folk, Nebraska 46 May22,'1964
<br />f. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />47�-�4-6455 HOSPITAL � InpaUent OTHE � Nursing HomefLTC � Haspice Facilily
<br />36. FACILITY-NAAAE (If �rot Ir�titudon, give street and number) � ER/Outpatlent ❑ DecedarR's Home
<br />' Saint Francis Medical Center ❑ oon ❑ Other (Speclfy)
<br />�c. CITY OR TOWN OF DEATH Qnclude Zip Code) Bd. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE 8b. COUNTY 8t. CITY OR TOWN
<br />Ne6ra§ka Hall Grand Island
<br />9d. STREEf AND NUMBER 9e. APT. NO. 8f. LP CODE 8g. WS1DE CITY LIMITS
<br />1404 West John 68801 ��s ❑ No
<br />10a. MARITAL STATUS AT TIME OF DEATH � Married ❑ Never NlarHed 10b. NAME OF SPOUSE (Firat, Middle, Last, Suffbc) If wHe, give malden �me
<br />❑ nnemaa, b�n ���cea ❑ v+nao�a ❑ nwo►cea p unw,ow„ Yvonda Beaudin
<br />td
<br />11. FATHER'S-NAME (First, Middte, Last, Suftix) 12. MOTHER'S•NAME (First, Middle, Malden Sumame)
<br />Eldon Hirsch Gwen Rauschke
<br />13. EVER IN U.S. ARMED FORCES? GNe dates ot aervlee (f Yae. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />�res, No, or Unk.) NO Yvonda Hirsch Wife
<br />'�S. MEfHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />❑ sur�i ❑ �o�at�on Not Embalmed November 17, 2010
<br />� CremaUon ❑ E�rtombmerrt 18d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN sTATE
<br />'❑ Removai ❑ oc►�er �sPec►ry� W��avm Memorial Park Crematory Grand Island Nebraska
<br />� 7a FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br />�' Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 68801
<br />8. PART I. Fr�Oerthe sltaln ot everA�dlseases, InJuriea, or comPlicatlons4hat dlrecGY caused the deatit. DO NOT e�Rer terml�l eventa such ae cardlac ertae4
<br />resplra0ory artest, w veirtrlcWar flbrWaaon without ahowing t1re edolagy. DO NOT ABBREVIATE. Fstar only o�re eause on a Wre. Add additlonal Ilves fl neceaeary.
<br />IMMEDIATE CAUSE:
<br />imnneou►recause�fl�i a)Multisystem Organ Failure
<br />disea� or wnditlon reaulUng
<br />in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />sa�,�a,m�y uee ��awo�a n b) Refractory Hypotension Of Unknown Cause
<br />am, �eaam¢ m sne cause narea
<br />on Idre a DUE TO, OR AS A CONSEQUENCE OF:
<br />Fr�ter the UNDERLYING CAUSE � C �
<br />(tli�ase or InJury fhat initlated
<br />the eve�rts reautting �n death) DUE TO, OR AS A CONSEQUENCE OF:
<br />� d)
<br />B. PART U. OTHER SIGNIFlCANT CONDITIONS�omiHlons contributing to tha death but not resulU� in the undertying cause
<br />Acute Pancreati�s, DiverUculfUs - Mild, Alcohol Abuse - Adive, Presumed Alcohol Related Liver Disease
<br />� Not P�eB� wlthin P� Y�'
<br />� Pregnant ffi tlme of tleath
<br />� Not P�eB� � PreBnairt whhin 4Y daYe of death
<br />� Not Pre8�8M, but pregnant 4S daya to 1 year before Aeath
<br />� Unlmown H pregnent withln the �st year
<br />2a. DATE OF INJURY (MO., Day, Yr.) ?2b. TIME OF
<br />:1a. MANNER OF DEATH 21b. IF TRANSPOF
<br />� Natural � HoMdde � DrivedGPeratm
<br />� AccldeM � Pending Inveetlgedon ❑ ��n8er
<br />� g�lride � Could not be determLred ❑ Pedestrlan
<br />� Othe* (8PecItY)
<br />I
<br />22c. PLACE OF INJURY-At home, tarm, street, factory, �� butldl
<br />INJURY AT WORK? I22e. DESCRIBE HOw INJURY
<br />❑ �S ❑ No
<br />LOCATION OF INJURY • STREET 8 NUMBER, APT.NO.
<br />OCCURRED
<br />cmrrtowri
<br />23a. DATE OF pEATM (Mo., Day, Yr.}-
<br />� November 15, 2010 s � �
<br />� 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH °
<br />Z November 17, 2010 04:14 PM g�<�
<br />� o . ro sne eeee a mr a�ow�eaee. a�sn oca,rrea �s ure ame. mm a�a P�ce � o
<br />� ena aue w tne cause(s) amtea.ls�e�re ana nfle) F & �
<br />$ Kimbe�y A. Mlckels, MD g s
<br />YES �I NO ❑ PROBABLY ❑ UNKNOWN � ❑ YES � NO
<br />UU1ne� I n LC Nrvv fwu�cea7 vr �.crt � �ncn �rn �.�n.w.. rr. �.��
<br />Cimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island,
<br />REGISTRAR'S SIGNATURE �},,._ I � ; � I ��i.
<br />STATE
<br />24a. DAR�S�GNE� �NTo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day,
<br />ZIP CODE
<br />OF DEATH
<br />PRONOUNCED DEAD
<br />pn the baeis W examinadon anNor ImeatlBatlon. ln my opinlon deaM occurred et
<br />Ure tlme, date end ptace and tlue to fhe muse(s) afeted. (SlBnature and Tltle)
<br />68803
<br />Not Appllcable iT 28a Is NO ❑ YES [] NO
<br />T Cfype or Prtrrt
<br />28b. DATE FlLED BY REGISTRAR (Mo., Day, Yr.)
<br />November 18, 2010
<br />APPROXIMATEINTERVAL
<br />0�et to daath
<br />Hours
<br />onsetto death
<br />HOUfS
<br />o�et to death
<br />Onsetto death
<br />r i. �s. was nneoica� �NeR
<br />OR CORONER CONTACTED?
<br />❑ YES Q NO
<br />c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES � NO
<br />d. WERE AUTOPSY FINDINGS AVAILA
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ res ❑ NO
<br />eo�trueUon site, etc. (SpeeiFy)
<br />
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