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WHEN TNS COPYCARR/ES THE RAISED SEAL OF THE NEBRASKA HEALTH ANDFA <br />SYSTEM lT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL JjeOOi? <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIOCS SEC <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS <br />AN <br />DATE OF ISSUANCE <br />JAN 112001 AssTrrAllirSr� <br />LINCOLN, NEBRASKA HEALTH AND HUMAN SEF <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SSiVMS 1 <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH <br />200107341 <br />drs+ � =, <br />.EY S 0 <br />TE RE61 <br />S <br />MANCEA <br />W SUPT <br />1 DECEDENT - NAME FIRST MIDDLE LAST <br />2 SEX • <br />3. DATE OF DEATH tMpnth. Da> Ye rri <br />Robert E. Goetsch <br />Male <br />December 28, 2000 <br />4 CITY AND STATE OF BIRTI+ 11 1noon USA.. namecountry) <br />Sa AGE - Last Binhday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Mont. Oa, year/ <br />M 1 ' DAYS <br />Sc. HOURS MINS. <br />1Yrsl 5b <br />Grand Island, Nebraska <br />76 <br />March 22, 1924 <br />7 SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH - <br />506-18-5792 <br />HOSPITAL ❑ Inpatient OTHER © Nursing Home <br />❑ ER Outpatient ❑ Residence <br />81b FACILITY - Name (d not mstitufion, give street and number/ <br />St. Francis Skilled Care Center <br />❑ DOA ❑ Other (Sp-4, <br />8c CITY. TOWN OR LOCATION OF DEATH <br />Bd INSIDE CITY LIMITS Be. COUNTY OF DEATH <br />Grand Island <br />Yes (Z No ❑ Hall <br />9a RESIDENCE - STATE <br />9b. COUNTY <br />9c CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (Including Zip Code) 9e INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />112 E. 14th St. 68801 Yes a Np ❑ <br />10 RACE - (e.g., White. Blank. American Indian. <br />11. ANCESTRY le g . Italian. Mer,can. German, etc) <br />12. ® MARRIED ❑ WIDOWED <br />13 NAME OF SPOUSE if/ wde give maiden Hama) <br />etc I [Specify) <br />White <br />(Specify) <br />American <br />NEVER DIVORCED <br />MARRIED <br />Florence Keithly <br />14a USUAL OCCUPATION JGwe kind o /work done during most 14D <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Speciy, only highest grade completed/ <br />of working life, even if retired/ <br />(petroleum) <br />�a en or cond (0 -12) College l ao, S•I <br />Mana er <br />Oi warehouse <br />�y <br />t rae <br />� <br />16 FATHER - NAME FIRST MIDDLE LAST <br />_ <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />�1, <br />Frank Goetsch <br />Pauline Perky <br />18 WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT NAME <br />(Yes. no. or unkf 111 yes. give war and dales of servlcesl <br />I <br />Yes II May 1943 -Dec. 1945 <br />Florence Goetsch <br />_ <br />19b INFORMANT MAILING ADDRESS (STREET OR R F D NO. CITY OR TOWN. STATE ZIPI <br />112 E. 14th St., Grand Island, Nebraska 68801 <br />20 EMBALMER - SIGNATURE 8 LICENSE NO <br />21 a METHOD OF DISPOSITION 21b DATE i 21c CEMETERY OR CREMATORY NAME <br />Not Embalmed <br />❑Bpr;al ❑Rempva'Dec. 29, 2000 Central Ne. Cremation Ser <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />22a FUNERAL HOME -NAME <br />Livingston - Sondermann F.H. <br />®Cremation ❑DOnaup Gibbon, Nebraska <br />22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR dOWN. STATE. ZIP( <br />601 N. Webb Road, Grand Island,•.Nebraska 68803 -4050 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR Ia). Ib), AND (cl) I Interval between onset and deal <br />� <br />�PAR(a) Q C CUB C1v-\ �' , ! IX �' ` `••' Vh W,� S <br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death <br />I <br />(b) .. <br />DUE TO OR AS A CONSEQUENCE OF Interval between onset and neam <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />If IF FEMALE. WAS THERE A 24 <br />AUTOPSY <br />25 WAS CASE REFERRED TO MEDICAL <br />PART 1 PREGNANCY <br />IN THE PAST 3 MONTHSn <br />-(� EXAMINER OR CORONERS <br />t ` <br />IAge510 -541 Yes No <br />Yes No <br />Yes No <br />26a <br />26b DATE OF INJU�Y ((,Mo.. Day Yr) <br />26c HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident F-] Undetermined <br />vA (\ <br />M <br />Suicide F Pending <br />26e. INJURY AT WORK <br />26f. PUKE OF INJURY - home. farm, street factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />f <br />Homicide Investigation <br />Yes No <br />❑ ❑ <br />If <br />o ce building. eta ($pecl/y) <br />27a, DATE OF DEATH (Mo.. Day. Yr) <br />28a DATE SIGNED (Mo.. Day Yr./ <br />28b TIME OF DEATH <br />�Z — 20B u� <br />a <br />i <br />M <br />i ° <br />27b. DATE SIGNED (Mo. Day Yr) <br />27c. TIME OF DEATH <br />28c PRONOUNCED DEAD (MO. Day. Yr.) <br />28d. PRONOUNCED DEAD (Hour) <br />d <br />k ^� Q <br />0� <br />x <br />I 3S 5 - P M <br />oN <br />giz <br />M _ <br />27d To the best of my knowletlge. a un ed ti to nd place and due to the <br />28e. On the basis of examination and or investigation, in my opinion death occurred at <br />° ° ° <br />Xcause(sl stated. __ <br />° <br />the time date and place and due to the cause(s) stated. <br />(Si nakee and Tide <br />(Signature arid Tide ) ► _ <br />29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? <br />30.a HAS ORGAN CA TISSUE DONATION BEEN CONSIDERED? 30.b <br />WAS CONSENT GRANTED? <br />-r ❑ YES 19 NO ❑ UNKNOWN <br />❑ YES 19 NO <br />x ❑ YES 19 NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY) 'Ie a Po,'v - <br />k Dr. S.L. Husen, M.D., 2116 W. Faidley Ave.,Suite 400, Grand Island, NE 68803 <br />32a REGISTRAR <br />32b. DATE FILED /Mo.. a <br />IH MISIAR <br />O rI <br />J 11\`11 2 <br />h'�}1jn <br />1pggonjy � <br />