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To be completed by: CERTIFIER if To be completed/verified by: FUNERAL DIRECTOR 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Paul Friedrich Gosda 2 ,' , ' M lle 1 3: DA,TF� O DEATH (Mo., Day, Yr.) . Febru 19, 2015 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Lenora, Oklahoma 5a. AGE - Last Birthday (Yrs.) 84 6b. UNDER 1 YEAR 5c. UNDER 1 DAY'',, ,ft' ATE OF BIRTH (Mo., Day, Yr.) ` November 2, 1930 MOS. DAYS HOURS MINS. 7. SOCIAL SECURITY NUMBER 508 -28 -9814 8b. FACILITY -NAME (If not Institution, give street and number) Tiffany Square Care Center 8a. PLACE OF DEATH HOSP ❑ Inpatient OTHER ® Nursing Home/LTC ❑ Hospice Facility ❑ ER/Outpatient ❑ Decedent's Home ❑ DOA ❑ Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Doniphan 9d. STREET AND NUMBER 12380 South Aida Road e. APT. NO. r 9f. ZIP CODE I 68832 9g. INSIDE CITY LIMITS ❑ YES ® NO 10a. MARITAL STATUS AT TIME OF DEATH ❑ Married ❑ Never Married ❑ Married, but separated ® Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) H wife, give maiden name Eunice K Harrell 11. FATHER'S -NAME (First, Middle, Last, Suffix) Fred H Gosda 12. MOTHER'S -NAME (First, Middle, Malden Surname) Emma E Niemoth 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 10/12/1948 - 09/15/1952 14a. INFORMANT -NAME Kirk D Gosda 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ® Burial ❑ Donation ❑ Cremation 0 Entombment ❑ Removal ❑ Other (Specify) 16a. EMBALMER - SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) February 24, 2015 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Grand Island City Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Apfel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Code 68801 CAUSE OF DEATH{ instructions and examples) 13. 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 respiratory great, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: onset to death IMMEDIATE CAUSE (Final a) COPD - End Stage Years disease or condition resulting In death) DUE TO, OR AS A CONSEQUENCE OF: 1 ; onset to death 8equsMially list conditions, if b) 1 arty, leading to the cause listed on line s. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death Enter the UNDERLYING CAUSE c) i (disease or Injury that initiated • the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: 1 onset to death LAST I d) 1 1 18. PART U. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. Bronchiectasis, Diastolic Heart Failure, Pulmonary Nodule, Hyperlipidemia, Pulmonary Hypertension 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ® NO 20. IF FEMALE: ❑ Not pregnant within past year ❑ P regnant at time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Unknown If pregnant within the past year 21a. MANNER OF DEATH ® Natural ❑ Homicide Accident Pending Investigation ❑ ❑ ❑ suicide ❑ could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 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) 22d. INJURY AT WORK? ❑ YES ❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE ;; W i G Eva 23a. DATE OF DEATH (Mo., Day, Yr.) February 19, 2015 B 1 i * I I ; ; ° u 12 a .8 a a 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) March 5, 2015 I 23e. TIME OF DEATH 11:30 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 8 4 0 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 2 Kimberly A. Mickels, MD 74e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Me) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ® YES ❑ NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES ❑ NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Kimberly A. Mickels, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803 r 28a. REGISTRAR'S SIGNATURE - 1 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) March 9, 2015 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OFJ-1EALTH AND HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBPASKA.DEPAPTMpVT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL, getOROS.' DATE OF ISSUANCE 03/11/2015 STATE OF NEBRASKA 201503094 ' s.TANLEY S .CCIQPER AA3!'ST VT STATE REGISTRAR DEP,AR TH AND STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAP4 SII V)PES, CERTIFICATE OF DEATH ; < ^.