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STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE4L.TOMMIION SERVICES,IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NeffRASKAVitEPARTAIENT OF HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY fgDR VITAL•REcORbS'. ),
<br /> /�
<br /> DATE OF ISSUANCE jcJ
<br /> •
<br /> 04/09/2014 ,_sT.AN Y C OP R .�
<br /> =ASISIT REGISTRA'/2
<br /> 0.126PARIN O T[AIVD
<br /> L.
<br /> LINCOLN, NEBRASKA r, Al,�l SER ,: ;'•, ••
<br /> STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN BIEI t S ti n i�� t`r .1 t".. . 14 01 692
<br /> •_ CERTIFICATE OF DEATH 1 ''�'' , ' '`
<br /> 1.DECEDENT'S-NAME (First, Middle, Last, Suffix) 2.SEX I A r 3.b TE.OF DEATH(Mo.,Day,Yr.r
<br /> Sister Mary Margaret McGowan SFCC Female - "' April 2,2014
<br /> 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.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> San Francisco,California 66 _ August 4,1947
<br /> 7.SOCIAL SECURITY NUMBER 8a.PLACE OF DEATH
<br /> 507-62-0602 HOSPITAL ®Inpatient OTHER ❑Nursing Home/LTC ❑Hospice Facility
<br /> 8b.FACILITY-NAME(If not institution,give street and number) ❑ER/Outpatient ❑Decedent's Home
<br /> IY
<br /> I- Saint Francis Medical Center ❑DOA ❑Other(Specify)
<br /> W 8c.CITY OR TOWN OF DEATH(Include Zip Code) 8d.COUNTY OF DEATH
<br /> IY
<br /> El Grand Island 68803 Hall
<br /> a 9a.RESIDENCE-STATE 9b.COUNTY 9c.CITY OR TOWN
<br /> z• Nebraska Hall Grand Island
<br /> O 9d.STREET AND NUMBER e.APT.NO. 9f.ZIP CODE I 9g.INSIDE CITY LIMITS
<br /> u.
<br /> • 1824 S.Blaine 68803 M YES ❑ NO
<br /> 1 10a.MARITAL STATUS AT TIME OF DEATH❑Married ®Never Married lob.NAME OF SPOUSE(First, Middle, Last, Suffix)H wife,give maiden name
<br /> !E ❑Married,but separated ❑Widowed ❑Divorced ❑Unknown
<br /> 11.FATHER'S-NAME (First, Middle, Last, Suffix) 12.MOTHER'S-NAME (First, Middle, Maiden Surname)
<br /> d Paul James McGowan Wauneta Bums
<br /> a.
<br /> E
<br /> 13.EVER IN U.S.ARMED FORCES? Give dates of service H Yes. 14a.INFORMANT-NAME 14b.RELATIONSHIP TO DECEDENT
<br /> 8 (Yes,No,or Unk.)No Sister Carlene Headrick SFCC Friend
<br /> 2 15.METHOD OF DISPOSITION 16a.EMBALMER-SIGNATURE 16b.LICENSE NO. 16c.DATE(Mo.,Day,Yr.)
<br /> 2 ®Burial ❑Donation
<br /> Patricia R.Curran 1092 April 7,2014
<br /> ❑Cremation 0 Entombment 16d.CEMETERY,CREMATORY OR OTHER LOCATION CITY/TOWN STATE
<br /> ❑Removal ❑Other(Specify)
<br /> Kearney Cemetery Kearney Nebraska
<br /> 17a.FUNERAL HOME NAME AND MAILING ADDRESS(Street,City or Town,State) 17b.Zip Code
<br /> Curran Funeral Chapel,3005 S.Locust St.,Grand Island,Nebraska 68801
<br /> CAUSE OF-DEATH(See instructions and examples)
<br /> '15.PART I.Enter the chain of events.-diseases,injuries,or complications-that directly caused the death.DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<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: onset to death
<br /> IMMEDIATE CAUSE(Final a)Acute Respiratory Failure Weeks
<br /> disease or condition resulting
<br /> M death) DUE TO,OR AS A CONSEQUENCE OF: . onset to death
<br /> Sequentially list conditions,If b)Acute Renal Failure Weeks
<br /> any,leading to the cause listed
<br /> on line a. DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE c)Chronic Renal Disease Weeks
<br /> (disease or injury that initiated
<br /> the events resulting In death) DUE TO,OR AS A CONSEQUENCE OF: onset to death
<br /> LAST d)Diastolic Heart Failure
<br /> Years
<br /> 18.PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given in PART I. 19.WAS MEDICAL EXAMINER
<br /> Pneumonia NOS,Diabetes,Obstructive Sleep Apnea,Cor Pulmonale,Anemia,Hypertension,Obesity OR CORONER CONTACTED?
<br /> ❑YES El NO
<br /> CY
<br /> W ,20.IF FEMALE: 21a.MANNER OF DEATH 21b.IF TRANSPORTATION INJURY 21c.WAS AN AUTOPSY PERFORMED?
<br /> • ®Not pregnant within past year ®Natural ❑Homicide ❑Driver/Operator ❑ YES ® NO
<br /> 0 Pregnant at time of death ❑Accident ❑Pending Investigation ❑Passenger
<br /> ❑Not pregnant,but pregnant within 42 days of death ❑Pedestrian 21d.WERE AUTOPSY FINDINGS AVAILABLE
<br /> ❑Suicide 0 Could not be determined TO COMPLETE CAUSE OF DEATH?
<br /> ❑Not pregnant,but pregnant 43 days to 1 year before death ❑Other(Specify)
<br /> I ❑Unknown If pregnant within the past year ❑ YES ❑ NO
<br /> E 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)
<br /> 8
<br /> 2 22d.INJURY AT WORK? 22e.DESCRIBE HOW INJURY OCCURRED
<br /> F
<br /> ❑YES ❑NO
<br /> 22f.LOCATION OF INJURY-STREET&NUMBER,APT.NO. CITY/TOWN STATE ZIP CODE
<br /> 23a.DATE OF DEATH(Mo.,Day,Yr.) 24a.DATE SIGNED(Mo.,Day,Yr.) 24b.TIME OF DEATH
<br /> k W April 2,2014 G
<br /> g E 23b.DATE SIGNED(Mo.,Day,Yr.) 23c.TIME OF DEATH 1 2 C Y 24c.PRONOUNCED DEAD(Mo.,Day,Yr.)24d.TIME PRONOUNCED DEAD
<br /> z April 7,2014 I 06:45 PM d<11
<br /> $@ N
<br /> u0 9d.To the best of my knowledge,death occurred at the time,date and place a E 24e.On the basis of examination and/or investigation,In my opinion death occurred at
<br /> 2 c and due to the cause(s)stated.(Signature and Title) B the time,date and place and due to the cause(s)stated.(Signature and Title)
<br /> s Kimberly A.Mickels,MD ~
<br /> 25.DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b.WAS CONSENT GRANTED?
<br /> ❑YES ® NO ❑PROBABLY ❑ UNKNOWN ❑YES
<br /> El NO Not Applicable If 26a is NO 0 YES ❑NO
<br /> 27.NAME,TITLE AND ADDRESS OF CERTIFIER(Type or Print
<br /> Kimberly A.Mickels,MD,729 North Custer Avenue,Grand Island,Nebraska,68803
<br /> 28a.REGISTRAR'S SIGNATURE /Jf J A c 28b.DATE FILED BY REGISTRAR(Mo.,Day,Yr.) I
<br /> April 8,2014
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