|
STATE OF NEBRASKA
<br />WHEN THIS COPY GARRIES rHE R.4ISED S L OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />7HE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMFNT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE /�/�JQ�� �.1 ' �'° " --
<br />05/17/2010 ,� 0��, 0���� STANLEY S. COOPER
<br />� ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH AND
<br />LINCOLN, NEBRASKA HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />/�L'�TICl/'►ATC AC 1'1BATL1 10 01344
<br />� v���� u �v�� � v� vr.n� � �
<br />1. DECEDENTS-NAME (Flrst, Middle, Last, Suffix) 2. SIX 3. DATE OF DEATH (Mo., Day, Yr.)
<br />Mark Thomas Placke Male May 4,, 2010
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Blrthday b. UNDER 1 YEAR 5c. UNDER 1 DAY 8. DATE OF BIRTH (Mo., Day, Yr.)
<br />(�'► M09. DAYS HOURS MINS.
<br />Grand Island, Nebraska 39 August 6, 1970
<br />7: SOCIAL SECURITY NUMBER ' Ba. PLACE OF DEATH
<br />¢�4-J$-9�j$2 HOSPITAL � Inpatient OTHER ❑ Nursing Home/LTC � Hosplce Faclllty
<br />8t�. FACILITY•NAME (H not Institutlon, g(ve street and number)
<br />� ❑ ER/OutpaBent � Decedent's Home
<br />° � 411 South Cedar ❑ DOA ❑ otner �speaty�
<br />U
<br />� Bc. CITY OR TOWN OF DEATH (Inetude Zip Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68801 Hall
<br />� 9d. RESIDENCESTATE 9b. COUNTY ' 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER 8e. APT. NO. 8f. ZIP CODE 8g. INSIDE CITY LIMITS
<br />� 411 South Cedar 68801 � ves ❑ No
<br />� 1Qa. MARITAL STATUS AT TIME OF DEATH ❑ Married � Never Marrled 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wHe, glve matden name
<br />� Q Married, but separated ❑ Wldowed ❑ Divorced ❑ U krrown
<br />d
<br />� 11. FATHER'S-NAME (Flrst, Middle, Last, SufFlx) 12. MOTHER'S•NAME (Flrat, Middle, Matden Surtrame)
<br />Larry Placke Kay Harvey
<br />°' 13. EVER IN U.S. ARMED FORCES? Give dates oT service If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />E
<br />� �ras, No, or unk.� No , Jon Placke Brother
<br />m 15. METHOD OF DISPOSITION 16a. EMBALMERSIGNATI�RE 78b. LICENSE NO. 76c. DATE (Mo., Day, Yr.)
<br />a
<br />f ? ❑ BuNal ❑ Dorratlon
<br />Not Embalmed May 5, 2010
<br />Q Crematlon ❑ E�ombmerrt 16d. CEMETERY, CREMATpRY OR OTHER LOCATION CI'fY / TOWN STATE
<br />❑ Remo�i ❑ ou�e� �sPe�uy� w��awn Memoria( Park Crematory Grand Island Nebraska
<br />17a. FUNERAL HOME NAME AND MAIUNG ADDRESS (Street, CI ', or Town, State) 17b. 2ip Code
<br />Apfel Funeral Home, 1123 W. 2nd, Grand Island, hdebraska 68801
<br />CAUSH OF DEATH See instructlons and exam es
<br />1& PART 1. F�ter the ehaln oi eve� diaeases, inJuries, or compllcatlon�thet directly caused the death. DO NOT enter terminal eveMS auch as cardiac artest, ; AppROXIMATE INTERVAL
<br />� raspiratory arreef, or ventricular flbrlliatlon without ahowing the etlology;; OD NO7 ABBREIMT& Errter only o�re puae on a Iine. Atld addidonal tl�res If necessary. i
<br />IMMEDIATE CAUSE: ; omset to death
<br />�mmeowrecnusecF,� a)Strangulation ; Immediate
<br />diseaee or condklon resuitlng _
<br />m deau�� DUE TO, OR AS A CONSEQUENCE pF: ! onset to death
<br />8equeMlaOy Ilst conditlona, If b) "
<br />anY. leading M the cause Ilsted
<br />on nrre a DUE TO, OR AS A CONSEQUENCE'bF: ; onset to death
<br />Eirterthe UNDERLYINO CAUSE C ) "
<br />(diaease or InJury fhat in(tiatetl
<br />the eveMe reauitlng In death) DUE TO, OR AS A CONSEQUENCE bF: � or�et to death
<br />u�sr d �
<br />18. PART U. OTHER SIGNIFICANT CONDITIONS-CondiUo�re coMributing to the death but not resultlng In the underlying cause gtven In PART I. 78. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />y . � YES ❑ NO
<br />W O, IF FEMALE: 21a. MfUVNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br />W
<br />� � Not pregnaM within past year � N8f ural � Homlcitle � DrivedOperator
<br />W � PragimM at tlme of tleath � Passenger ❑�S � NO
<br />V � �ae�rt � Pentlinglnveatleatlon
<br />�] Not pregnaM, but pregnam within 42 aays oi death � PedeeWan 21 d. WERE AUTOPSY FINDINGS AVAILABLE
<br />�` � Suhdde � Could not De determltretl TO COMPLETE CAUSE OF DEATH7
<br />, � Not Pre9�aM. but PreBnaM 43 days to 1 year beTO�e death � OGter (SPe��%)
<br />+% [� Unlmown H pregnaM wtthin ttre past year ❑ YES ❑ NO
<br />d
<br />E 27s. DATE OF INJURY (Mo., Day, Yr.) ZZb. TIME OF INJURY,I 22c. PLACE OF INJURY-At home, farm, street, factory, offlce bullding, corretructlon stte, eta (SpecHy)
<br />8 May 3, 2010 Unknown Home
<br />� 27d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />F Hung by extension cable in decedent's garage.
<br />❑ ves � No
<br />2T�f. LOCATION OF INJURY • STRBET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />e411 Cedar Street, Grand Island Nebraska 68801
<br />23a. DATE OP DFATH (�Io., Day, Yr.�--_ _ __ __ 24a, DAT� SIGNEB-fMo� Day,lfrj =_ Z46: TIME OF DEATFf. _,- --,,- -
<br />.� S�� May 5, 2010 Approx. 01:00 AM
<br />�', �} 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF G�EATH �� k r 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />�; � Z � a<� Ma 4, 2010 11:50 PM
<br />$ � 3tl. To the beat oi my knowletlge, tleath ocCUrred ffi the Ume, date'�,�nd place �� 24e. On the besis of axaminadon amUor InvesUgatlon, In my opinlon tleatB ocwrrett at
<br />o;� and due W the cauae(s) afatetl. (Stgnature anq Tftle) ' ��� ��, �e and place and due to Me eauee(e) stated. (Signature and Tkle)
<br />~ '" g o Martin Klein, Hall Deputy County Attomey
<br />2�. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 2. HAS ORCiAN OR TISSUE DONATION BEEN CONSIDEREDT 28b. WAS CONSENT GRANTED?
<br />❑ YES ❑ NO � PROBABLY � UNFdJOWN Q YES � NO NotApplicable it26a is NO � YES ❑ NO
<br />2. E, TITLE D ADDRESS F CERTIFIER (P I IAN, C I ANT, CORO ER P R A O ype or PrIM)
<br />Martin Klain, Hall Deputy County Attomey, 231 S.,jLocust, P.O. Box 367, Grand Island, Nebraska, 68802
<br />28h. REGISTRAR'S SIGNATURE �� 28b. DATE FlLED BY REGISTRAR (Mo, Day, Yr.)
<br />May 17, 2010
<br />
|