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STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALT fiAND_HUMANSERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL -RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STAFISPO SECTIOIWi.W1jCH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. - - " DATE OF ISSUANCE OCT 0 4 2006 LINCOLN, NEBRASKA 201503766 TANLEY S.t0gPER ASSISTANT T STE EGISTRAR HEALTH AND HU MkN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT CERTIFICATE OF DEATH O 30641 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday Grand Island, Nebraska (Yrs.) 86 MOS. 18. 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, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final diseaseor condition resulting In death) Sequentially llst conditions, it any, leading to the cause listed on line a. Enterthe UNDERLYING CAUSE (disease or injury that Initiated the events resuhtngin death) LAST (a) Cardiac arrest DUE TO, OR AS A CONSEQUENCE OF: (e) Coronary Artery disease DUE TO, OR AS A CONSEQUENCE OF: m Congestive Heart Failure DUE TO, OR AS A CONSEQUENCE OF: APPROXIMATE INTERVAL onset to death immediate onset to death 25 years onset to death onset to death 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEE CONSID RED? ❑ YES ❑ NO ❑ PROBABLY X❑ y UNKNOWN ❑ YES L'J` NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Ka E Trac De. Hall Count Attorne 231 S Locust Grand Island NE 24c. PRONOUNCED l DEAD LM y, Yr.) P 2006 6 24e. On the ba° of examination and /or investigation, In my opinion death occurred at the im a d to a = and due to the cause(s) stated. (Signature and Title ) y 26b. WAS CONTENT GRANTED? yy Not Applicable f 26a is NO ❑ YES I2 NO 1. DECEDENT'S -NAME (First, Glenn Middle, George Last, Gosda 7. SOCIAL SECURITY NUMBER 507 -30 -9720 8b. FACILITY -NAME (If not institution, give street and number) 4014 Mason Ave. 5b. UNDER 1 YEAR 8c. CITY OR TOWN OF DEATH (include Zip Code) Grand Island, Nebraska 68803 9a. RESIDENCE -STATE Nebraska 13. EVER IN U.S. ARMED FORCES? Give dates of service if yes. (YMr unk.) 12/30/41-7/26/45 15. METHOD OF DISPOSITION Burial ❑ Donation ❑ Cremation ❑ Entombment ❑ Removal ❑ Other (Specify) 9b. COUNTY Hall 11. FATHER'S -NAME (First, Middle, Fred Hu•o Last, Suffix) Gosda 23a. DATE OF DEATH (Mo., Day, Yr.) 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 23d. To the best of my knowledge, death occur ed at the time, date and place and due to the cause(s) stated. (Signature and Title ) y • 9c. CITY OR TOWN Grand Island HOURS ed. COUNTY OF DEATH Hall 9e. APT. NO 9f. ZIP CODE 68803 9g. INSIDE CITY LIMITS IPI YES ❑ NO 1 0a. MARITAL STATUS AT TIME OF DEATH Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Wilma Cushman 12. MOTHER'S -NAME (First, Emma Middle, Malden Surname) E. Neimoth 14a. INFORMANT -NAME Wilma Gosda 14b. RELATIONSHIP TO DECEDENT Wife 16d. CEM T 'Y, CREMATORY 0 HER LOCATION Grand Island City Cemetery CITY / TOWN 18c. DATE (Mo., Day, Yr. ) Sept. 26, 2006 STATE Grand Island, Nebraska 16b. LICENSE NO, 1328 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? YES ❑ NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES I NO 21a. MANNER OF DEATH ❑ Natural ❑ Homicide ❑ Accident Pending Investigation ❑ Suicide ❑ Could not be determined 21b. IF TRANSPORTATION INJURY ❑ Driver /Operator ❑ Passenger ❑ Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? OYES ❑ NO 22c.PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 24d. TIME PRONOUNCED DEAD 11:00 am m 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) OCT 2 2006 8a. PLACE OF DEATH HOSPITAL: ❑ Inpatient OTHER: ❑ ER /Outpatient ❑D04 17a. FUNERAL HOME NAME AND MAIL NG ADDRESS (Street, City or Town, State) All Faiths Funeral Home,2929 S. :Locust St. Grand Island, NE 18. PART II. OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20. IF FEMALE: ❑ Not pregnant within past year ❑ Pregnant 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 22a. DATE OF INJURY (Mo., Day, Yr.) 22d. INJURY AT WORK? ❑ YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO. 22b. TIME OF INJURY m 22e. DESCRIBE HOW INJURY OCCURRED CITY/TOWN 2. SEX Male 5c. UNDER 1 DAY MINS. 3. DATE OF DEATH (Mo., Day, Yr.) "Sept. 21, 2006 8. DATE OF BIRTH (Mo., Day, Yr.) Febr. 21, 1920 ❑ Nursing Home/LTC ❑ Hospice Facility Decedent's Horne ❑ Other (Specify) 17b. Zip Code 68801 STATE ZIP CODE