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STATE OF NEBRASKA WHEN ` THIS i COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS ie RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH DATE OF ISSUANCE 11/27/2018 LINCOLN, NEBRASKA 20190493$ Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death.1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Charles Francis McGowan 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) November 6, 2018 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) Greeley, Nebraska (Yrs.) 88 MOS. DAYS HOURS MINS. July 2, 1930 7. SOCIAL SECURITY NUMBER 568-30-9454 8a. PLACE OF DEATH HOSPITAL ® Inpatient OTHER 0 Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CH1 Health St. Francis 0 ER/Outpatient ❑ Decedent's Home 0 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 Grand Island -1. STREET AND NUMSSR me. APT. NC. 9i. ZIP CODE 1107 S. Greenwich I I 68801 9g. INSIDE CITY LIMITS ® YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH ® Marded 0 Never Married ❑'Married, but separated; ❑ Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Kathryn L Davis 11. FATHER'S -NAME (First, Middle, Last, Suffix) Thomas McGowan 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Margery Whalen 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) Yes 10/13/1948-07/10/1950 14a. INFORMANT -NAME Kathryn L McGowan 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF':DISPOSITION ® Burial 0 Donation 16a. EMBALMER -SIGNATURE Patricia R. Curran 16b. LICENSE NO. 1092 16c. DATE (Mo., Day, Yr.) November 12,2018 ❑ Cremation 0 Entombment ❑ Removal ,❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Westlawn Memorial Park Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Curran Funeral Chapel, 3005 S. Locust St., Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 16. 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 arrest, or vemr!tutar 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 a) Aspiration Pneumonia disease or condition resulting onset to death 24 Hours in death) '. DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b)Subdural Hematoma Traumatic any, Wading to thecause listed'' onset to death'.. 10 Days on line a. DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Fall At Home (disease or injury that initiated onset to death 10 Days the events resultingtn death) DUE TO, OR AS A CONSEQUENCE OF: LAST ; d) onset to death 18. PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: ':. 0 Not pregnant within past year 0 Pregnant at time of death 21a. MANNER OF DEATH 0 Natural 0 Homicide ® Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator 0 Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ®NO ❑ Not pregnant, but pregnant within 42 days of death o Not pregnant, but pregnant 43 days to 1 year before death 0 I./nknown if pregnant within the past year 0 Suicide 0 Could not be determined 0 Pedestrian ❑:Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE. TO COMPLETE CAUSE OF DEATH? 0 YES 0 NO 22a. DATE Gr INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURV-A: home, farm, street, factory, office bu i bog, construction site, au -(Specify) October 27, 2018 Unknown I Home 22d. INJURY AT WORK? u YES NO 22e. DESCRIBE HOW INJURY OCCURRED tripped 22f. LOCATION OF INJURY STREET 8, NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 1107 Greenwich, Grand Island Nebraska 68801 To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) November 6 2018 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) November 27, 2018 23c. TIME OF DEATH 09:35 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD r 3d. To the best o1 my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) John A. Wagoner, MD 24e. On the basis o1 examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES ® NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES ® NO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO ❑ YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) John A. Wagoner, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE _ 28b. DATE FILED BY REGISTRAR (Mo.. Day, Yr.) November 27, 2018 �`rf-