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<br />WHEN THIS 4 `° COPY CARRIES THE RAISED SEAL' OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE 'A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS if
<br />RUSSELL FOSLER
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE, OF DEATH
<br />©/56)T2e tLANCE
<br />LINCOLN, NEBRASKA
<br />O
<br />a,
<br />t
<br />8
<br />Y,7
<br />201907601
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Edward Glen Gowlovech
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 19, 2019
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Phillips, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />506-50-9984
<br />5a. AGE - Last Birthday
<br />(Yrs.)
<br />77
<br />FACILITY -NAME (If not Institution, give street and number)
<br />28.11 FartWorth AV
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 68803
<br />513. UNDER 1 YEAR
<br />MOS. DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />5c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 30, 1942 '+
<br />OTHER 0 Nursing Home/LTC
<br />® Decedent's Home
<br />0 Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />0 Hospice Facility
<br />RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d. STREET AND NUMBER
<br />2811 Fort Worth AV
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g. INSIDE CITY(iiMITS"
<br />II YES ❑ NO
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />s ❑:Married, but separated; ❑ Widowed 0 Divorced ❑ Unknown
<br />«
<br />11. FATHER'S-NAmE (First, MiuOHe, Last, Suffix)
<br />Edward L Gowlovech
<br />re
<br />I
<br />to
<br />at
<br />3
<br />13. EVER IN U.S.ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or link.) Yes 02/01/1961-05/18/1964
<br />15. METHOD OF DISPOSITION
<br />❑'Burial ❑ Donation
<br />® Cremation 0 Entombment
<br />❑ Removal 0 Other(Specify)
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br />Barbara Jane Bryant
<br />12. MtT'HER'S.NAME (First, Middle, Malden Surname)
<br />Laura E Wadkins
<br />14a. INFORMANT -NAME
<br />Barbara Jane Gowlovech
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Wife
<br />16c. DATE (Mo., Day, Yr.)
<br />October 19, 2019
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />CITY / TOWN
<br />Central Nebraska Cremation Services Gibbon
<br />STATE
<br />Nebraska
<br />17a. FUNERAt:HOME tows AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel. 3005 S. Locust St.. Grand Island. Nebraska
<br />17b,21p Code
<br />68801
<br />CAUSE OF DEATH (See instructions and examples)
<br />1i PART L Enter the chain of events. diseases, injuries, or complicationsd at directly caused the bath DO NOT entertensumal avants such as cardiac arrest,
<br />fgspiratary arrest, or ventrtular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line.: Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Respiratory Failure
<br />disease or condition resulting
<br />Sequentially list tat*ditlons, if
<br />any, leading to tiw CauSe listed.:
<br />on lines.
<br />Enter the UNDERLYING CAUSE
<br />(disease orinjury:that initiated..
<br />t e esents taauking in death)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)End Stage Liver Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />c) Chronic Kidney Disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)Crohns Disease
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />< 2 Days
<br />onset to death
<br />> 6 Months
<br />onset to death
<br />> 6 Months
<br />onset to death
<br />> 1 Year
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />Anemia Due To Myeloproliferative Disorder
<br />20. IF FEMALE:.
<br />0 Not pregnentlaithin past year
<br />.0
<br />St. 0 Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />g
<br />22a. DATE OF INJURY (Mo., Day, Yr.) I22b. TIME OF INJURY
<br />❑ Nat pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown If ~art -within the past year
<br />21a. MANNER OF DEATH
<br />Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />0 Suicide ❑ Could not be determined
<br />N
<br />0
<br />M
<br />to
<br />8
<br />to
<br />22d. INJURY AT WORK?
<br />AYES ONO
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑ Other(Specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />❑ YES NO
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ® NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY STREET 8 NUMBER, APT.NO.
<br />CITY/TOWN
<br />STATE
<br />ZIP CODE
<br />0
<br />2 Y
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />October 19 2019
<br />23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH
<br />October 19, 2019 04:20 AM
<br />3d. To the best of my knowledge, death occurred at the time, date and place
<br />and due to the causing) stated. (Signature and nue)
<br />Jennifer L. Brown, MD
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES NO ❑ PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.
<br />24d. TIME PRONOUNCED DEAD
<br />24e. On the basis of examination and/or Investigation, M my opinion death occurred at
<br />the time, date and place and due to the causes) stated. (Signature and Tills)
<br />26a. HAS ORGAN OR TISSUE DONATION ATION BEEN CONSIDERED?
<br />❑ YES
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jennifer L. Brown, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />tea. REGISTRAR'S
<br />SIGNATURE I�
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a is NO 0 YES 0 NO
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />October 23, 2019
<br />
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