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<br />STATE OF NEBRASKA ;
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<br />WHEN THIS 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
<br />DATE OF ISSUANCE
<br />1/4/2021
<br />LINCOLN, NEBRASKA
<br />202100237
<br />l 7
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<br />SARAH BOHNENKAMP
<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 />20 18723
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<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Victor Leon Gosda
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.) };
<br />November 19, 2020
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />near Lenora, Oklahoma, Oklahoma
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />91
<br />5b. UNDER 1 YEAR
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mo., Day, Yr.)
<br />May 5, 1929:
<br />7„SOCIAL SECURITY NUMBER
<br />506-28-9736
<br />eb. FACILITY•NAME((f'not Institution, give street and number)
<br />The Heritage at Sagewood
<br />8a. PLACE OF DEATH
<br />HOSPITAL 0 Inpatient
<br />ER/Outpatient
<br />❑ DOA
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedent's Home
<br />E Other (Specify)ASSISTED LIVING
<br />HospiceFaciltty
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code) I8d. COUNTY OF DEATH
<br />Grand Island 68803 Hall
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9d<STREETAND NUMBER
<br />1920 Sactewood Avenue
<br />De. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />9g INSIDE
<br />Da YES
<br />CITY LIMITS
<br />p•No'
<br />10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name'
<br />Leola May Wilson
<br />11, FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Fred Gosda
<br />1 12. MOTHER'S -NAME (First, Middle, Maiden Surname}
<br />Emma Niemoth
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes, No, or Unk.) Yes 05/03/1948-12/11/1952
<br />14a. INFORMANT -NAME
<br />Leola May Gosda
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />15. METHOD OF DISPOSITION
<br />ka Burial $ 0 Donation
<br />Crema6CM ❑ Entorttbment
<br />Removal < ❑Other (Specify)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16b. LICENSE NO.
<br />16c. DATE (Mo., Day, Yr,)___
<br />November 25, 2020
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Grand Island City Cemetery Grand Island
<br />STATE
<br />Nebraska
<br />17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State)
<br />All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />17b. Zip Code
<br />68801:.
<br />CAUSE OF DEATH (See instructions and examples)
<br />18. PART I. Enter the chain of events- -disuses, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE CAUSE:
<br />a) Gun Shot Would To The Head
<br />IMMEDIATE CAUSE (Final
<br />disease or condition reautfinp
<br />In death)
<br />Sequentially list conditions, it
<br />any, leading to the cause listed
<br />on lila a.
<br />Enter the UNDERLYING CAUSE
<br />(dideade or Injury that initiated
<br />the events resulting in death)
<br />LAST
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />Minutes
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Depression
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />lit PART 11. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I.
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />E YES ❑ NO
<br />20. IF FEMALE:
<br />❑'%Nat pregnant within pest year
<br />Pregnant tit the► of dash
<br />U:_ Hot pregnadt, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown It pregnant within the past year
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />0 Accident 0 Pending Investigation
<br />E Suicide 0 Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />❑ YES ENO
<br />21d. WERE AUTOPSY. FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO;
<br />22a: DATE OF INJURY (Mo., Day, Yr.)
<br />November 19, 2020
<br />22b. TIME OF INJURY
<br />Unknown
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc, ($pecify)
<br />Nursing Home
<br />22d. INJURY AT WORK?
<br />❑ YES E NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />Decedent shot himself in the head with a revolver.
<br />22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN
<br />1920 Sagewood, Grand Island
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />STATE
<br />Nebraska
<br />ZIP CODE
<br />68801 .
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />23d, To the bat of my knowledge, death occurred at the time, date and place
<br />and due to the causes) stated. (Signature and Title)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES ® NO ❑ PROBABLY 0 UNKNOWN
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />December 28, 2020
<br />24b. TIME OF DEATH
<br />Approx. 12:01 AM
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />November 19, 2020
<br />24d. TIME PRONOUNCED DEAD
<br />06:45 AM
<br />24e. On the basis of examination and/or investigation, in my opinion death wtcurreaet
<br />Inc time, date and place and due to the cauais) stated. (Signature anti Title)
<br />Benjamin W Shanahan, Deputy County Attorney
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES E NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a is NO ' 0 YES 0 NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Benjamin W Shanahan, Deputy County Attorney, 231 South Locust St, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />.2 _17
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />December 28, 2020
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