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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR- VIER Cd11
<br />DATE OF ISSUANCE
<br />MAR 112015
<br />LINCOLN, NEBRASKA
<br />202201198
<br />`'73TANLEY"S. COOPER ' ' ►
<br />'ASSLSTANT STATE REGISTRAR
<br />:01!P4RTMENT.OF. HEALTH:
<br />'`9 yf31�AN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER,;
<br />CERTIFICATE OF DEATH
<br />1. DECEDENT'S -NAME (First, Middle, Last, Suffix)
<br />John Joseph McGowan
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Greeley, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />Ce 508-30-4213
<br />Bb. FACILITY -NAME (it not Institution, give street and number)
<br />re
<br />c 1604 W. Division
<br />J 8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />W Grand Island 68801
<br />9a. RESIDENCE -STATE
<br />U-
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />FE 1604 W. Division
<br />6a. AGE -Last Birthday
<br />(Yrs.)
<br />81
<br />6b. UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5,-21?
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL: 0 Inpatient
<br />❑ ER/Outpatient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />8. DATE'OP'."BIRTN (Mo., Day, Yr.)
<br />March 20, 1933
<br />OTHER 0 Nursing Home/LTC 0 Hospice Facility
<br />® Decedent's Home
<br />0 Other(Speclfy)
<br />Bd. COUNTY OF DEATH
<br />Hall
<br />9b. COUNTY
<br />Hall
<br />9c. CITY OR TOWN
<br />Grand Island
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68801
<br />9g. INSIDE CITY LIMITS
<br />® Yes 0 No
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />W0 Married, but separated 0 Widowed ❑ Divorced 0 Unknown
<br />a
<br />E
<br />O
<br />Thomas McGowan
<br />1013. NAME OF SPOUSE (First, Middle, Last, Suffix) I wife, give maiden name.
<br />Doloris Kowalewski
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />co
<br />I
<br />O
<br />I-
<br />i
<br />12. MOTHER'S -NAME (First, Middle, Malden Surname)
<br />Marjorie Whalen
<br />13. EVER IN U.S. ARMED FORCES?
<br />Give dates of service N Yes.
<br />0/1951-09/27/1954
<br />(Yes, No, or Unk.) Yes 09/2
<br />16. METHOD OF DISPOSITION
<br />®Burial ❑Donation
<br />❑Cremation ❑Entombment
<br />❑Removal ❑OthenSpecify)
<br />14a. INFORMANT -NAME
<br />Doloris McGowan
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />i 7
<br />16a.. EMBALMER -SIGNATURE
<br />/ /
<br />/
<br />16d. CIMETERY, CREMATO OR OTHER LOCATION
<br />Westlawn Cemetery
<br />16b. UCENSE NO.
<br />16c. DATE (Mo., Day, Yr.)
<br />February 26, 2015
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Curran Funeral Chapel, 3005 S. Locust St., Grand Island, Nebraska
<br />CITY/TOWN
<br />Grand Island
<br />CAUSE OF DEATH (See instructions and examples)
<br />111. PART I. Enter the Thain of events - di Injuries, or complications -that directly caused the death. DO NOT enter terminal events sucn as cardiac west,
<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 />IMMEDIATE CAUSE (Final 4 is 6 - tet.
<br />disease or condition resulting a) IINy 1Ii1 tit"-� -- / �'�i ['�(N
<br />In death) -"NL
<br />DUE TO, OR AS A CONSEQUE E OF.
<br />Sequentially list conditions, U b)
<br />any, leading to the cause listed
<br />on line a.
<br />STATE
<br />Nebraska
<br />17b. Zip Code
<br />68801
<br />APPROXIMATE INTERVAL
<br />onset to death
<br />onset to death
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Enter the UNDERLYING CAUSE c)
<br />onset to death
<br />(disease or Injury that initiated
<br />the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST
<br />D:
<br />W
<br />LL
<br />re
<br />W
<br />0
<br />a
<br />N
<br />N
<br />a
<br />E
<br />O
<br />0
<br />m
<br />O
<br />I -
<br />d)
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART L
<br />onset to death
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER COpITACTED?
<br />❑ YES 12'NO
<br />20. IF FEMALE:
<br />❑ Not pregnant within past year
<br />❑ Pregnant at time of death
<br />❑ Not pregnant, but pregnant within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown if pregnant within the past year
<br />21a. MNER OF DEATH
<br />ural 0 Homicide
<br />❑ Accident 0 Pending Investigation
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />0 Passenger
<br />❑ Pedestrian
<br />❑ Other (Specify)
<br />21c. WAS AN AUTOPSY RFORMED?
<br />❑ YES aNO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAySE OF DEATH?
<br />DYES 5140
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22b. TIME OF INJURY
<br />rn
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />22d. INJURY AT WORK?
<br />❑ YES ❑ NO
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY - STREET & NUMBER, APT. NO.
<br />P
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 21, 2015
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />February 23, 2015
<br />23c. TIME OF DEATH
<br />7:01
<br />Pin
<br />23 . o t best of my kowle e, death occurred at the time, date and place
<br />e to the caut�e(s) aced. (Signature and Title)
<br />25. DID TO CerSE CONTRIBUTE TO T/IIE DEATH?
<br />❑ YES !. / 0 ❑ PROBABLY ❑ UNKNOWN
<br />.0 VZ
<br />Ce
<br />}00
<br />2 S
<br />aa6 J
<br />z
<br />F0
<br />00
<br />0 O J
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />STATE ZIP CODE
<br />24b. TIME OF DEATH
<br />m
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOUNCED DEAD
<br />m
<br />24e. On the basis of examination and/or Investigation, In my opinion death occurred
<br />at the time, date and place and due to the cause(s) stated. (Signature end Title)
<br />26e. HAS ORGAN OR TISSUE D NATION BEEN CONSIDERED?
<br />❑ YES NO
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable if 26a Is NO 0 YES O
<br />27. NAM T ' E AND ADDRESS OF CERTIFIER (Type or Print)
<br />John A. Wagoner M.D. 800 N. Alpha St. Grand Island, NE 68803
<br />28a. REGISTRAR'S SIGNATURE
<br />64294,
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />MAR .3 2015
<br />i
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