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20000343N WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. DATE OF ISSUANCE ,'L JUN 1 5 194 ANLEY S. COOPER ASSISTANT STATE REGISTRAR r97 LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT VITAL STATISTICS rPID TTI7Tf A 7= me no A ru ,_... _...,.. -. PART ,a. .w. mlerval between onset and podln I lal DUE TO, OR AS A CUN3EOUENCE OF tme.,:a beNvea nr.sel any ^ -�^ 111 DUE TO, OR AS A CONSEOUENCE OF Irnervoi between onset ann nearr (cl OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the Beam DIn not related PART PART I. DECEDENT - NAME FIRST MIDDLE LAST 2 SEX 3. DATE OF DEATH /Mourn Day Year) 11 PREGNANCY Helen Arvida Goodrich I Female May 26, 1999 4. CITY AND STATE OF BIRTH /M not h US. A. rums colmrry/ 5a AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH lMonlA Day Year/ 5b MOS I DAYS Sc.HOURS' MINS Rosie, Arkansas (Yrsl 72 Cl M.,ay 29, 1926 7. SOCIAL SECURTIY NUMBER ea PLACE OF DEATH 509 -24 -3663 HOSPITAL ❑ kw hen! OTHER ❑ Nursmg Home - -- ❑ ER Outpatient © Res.derlce 8b. FACILITY -Name /Mrlol rnsaluban, gve sheer antl number/ 1204 West First ❑ DOA ❑ Other /Spar,", 8c. CITY TOWN OR LOCATION OF DEATH Btl INSIDE CITY LIMITS Be COUNTY OF DEATH Grand Island, Nebraska Yes X❑ Np ❑ Hall ga. RESIDENCE - STATE 9b. COUNTY 9c CITY. TOWN OR LOCATION 9d STREET AND NUMBER /ktcludMZjo Code) - 9e INSIDE CITY LIMITS Nebraska Hall Grand Island 1204 West First 68801 Yes ® No ❑ 10. RACE - (e.g., While. Black. Amenpan hWan. 11. ANCESTRY leg.. Italian. Me.rcan. German, elcl 12. ® MARRIED ❑WIDOWED 13 NAME OF SPOUSE /M wile give maiden name/ e10 (Specify) White (Sohn " ) American NEVER DIVORCED MA Robert L. Goodrich Ida USUAL OCCUPATION /Give kiMd wdk due drwiig mosr d waking li/e, eren i/re(ire0l Idb KIND OF BUSINESS INDUSTRY 15 EDUCATION (Specify only highest grace completed) 1` Elenuntrf Secondary 10121 College 11 4ol 5 -I Waitress Food Service 16 FATHER - NAME FIRST MIDDLE UST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME ' Dalous Coleman Viola Martin 18 WAS DECEASED EVER IN U.S. ARMED FORCES? t9a INFORMANT -NAME (Yes no, or auk) i No IN yes. give war and dates M serf c"j (Signature and Tide Robert L. Goodrich 19b. INFORMANT MAILING ADDRESS (STREET OR R D NO.. CITY OR TOWN STATE. ZIPI - 4 West First Grand Island, Nebraska 68801 20 EMB LIVER - SIGNATURE 8 LICENSE NO Q jl `� 2 1 a METHOD OF DISPOSTION 21b. DATE 21c. CEMETERY OR CREMATORY NAME 31 NAMF 1Nn ♦fyflGFCC ne r•eoneieo rouver.. ..........r ................... ®Burial ❑ Removal May 29, 1999 Westlawn Memorial Park 2a. FUNERAL E -NAM _ 2" CEMETERY OR CREMATORY LOCATION CITv OR TOWN STATE Apfel- Butler - Geddes ❑ Cremation ❑ Donauon Grand Island, Nebraska 221 FUNERAL HOME ADDRESS (STREET OR FIF D NO CITY OR TOWN. STATE. ZIPI - 1123 West Second Street Grand Island, Nebraska 68801 ,_... _...,.. -. PART ,a. .w. mlerval between onset and podln I lal DUE TO, OR AS A CUN3EOUENCE OF tme.,:a beNvea nr.sel any ^ -�^ 111 DUE TO, OR AS A CONSEOUENCE OF Irnervoi between onset ann nearr (cl OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the Beam DIn not related PART PART lu IF FEMALE WAS THERE A 24 AUTOPSY 25 WAS CASE REFERRED TO MEDICAL 11 PREGNANCY IN THE PAS, 3 MONTHS? EXAMINER OR CORONER' (Ages 1054) Yes n No Yes No Yes No 26a 26b DATE OF INJURY /Mo. Day Yr/ 26c HOUR OF INJURY 26d DESCRIBE HOW INJURY OCCURRED Acadent Undetermined M SU4Ide Penomg 26e INJURY AT WORN PLpCE QF INJURY - At home. farm street fact" office 1w�lding. etc lSpedNl 26g LOCATION STREET OR RF.O. NO CITY OR TOWN STATE Homicide Invesugabon Yes No ❑ ❑ [261 27a. DATE OF DEATH /Mo. Day Yr.) 28a DATE SIGNED /Mo Day Yr/ 281 TIME OF DEATH a< _ 01 _ approx 27b DATE SIGNED /Mo.. Day Yrl 27c TIME OF DEATH 28c PRONOUNCED DE /MO. Day r.) 28d DE D • llbun 7�)NCED M ° M 27d To the best of my knowledge . death occurred at the eme, date and place and due to the the i of 'exam n a 1n st t n m m dea fired at Causelsl slated. °u b the bme. date and da no u sl 47a1 (Signature and Tide nature artd Tale 29. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? '77RAi4TED? ❑ YES ❑ NO Ik UNKNOWN ❑ YES IVI NO (—� YES V I NO 7b 31 NAMF 1Nn ♦fyflGFCC ne r•eoneieo rouver.. ..........r ................... .... ..... ..._... ___.._. l��