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<br />STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, ITCERTIFIES THE DOCUMENT BELOW TO
<br />BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH 7711E NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
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<br />DATE OF ISSUANCE
<br />9/25/2023
<br />LINCOLN, NEBRASKA
<br />202
<br />SARAH BOHNENICAMP
<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 />1. DECEDENT'S -NAME (First Middle, Last, Suffix)
<br />Cyndia_;Lea Gosda
<br />4'c(TYAND STATEOR7'ERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand island, Nebraska
<br />7, 8GIAi SECURITY NL(MBER
<br />308.66-4557
<br />5a AGE .Last iOlithday:
<br />(Yrs.)
<br />71
<br />8b.;FACiLrtY-filAME (If not Instituson
<br />CHI Health St. Francis
<br />ive street and number)
<br />8c.:CITY OR TOfWN OF DEATH (Include Zip Code)
<br />Grand island 88803
<br />9a. RES1DENCE STATE
<br />Nebraska
<br />9d.STREET'AID NUMBER
<br />5074 W :White Cloud Rd
<br />9b. COUNTY
<br />Hall
<br />5b, UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8e. PLACE OF;DEATH
<br />HOSPITAL Inpatient
<br />ER/Outpatient
<br />0 DOA
<br />10a MARITALSTATUS TIME OF DEATH I Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER S -NAME (First, Middle, Last, Suffix)
<br />F avrnond' Behr%no
<br />13. EVER IN CS: ARMEt FORCES?- Give 'dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />16. METHOD CIF DISPOSITION
<br />Burial ©Donation
<br />❑ Cremation ©Entombment
<br />❑Removal:; ❑ Other (Speclfy)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />23 12748
<br />3. DATE OF''DEATf(:(Mo., piiii )
<br />September 20?3
<br />6. DATE OF BIRU4(Mo. DlryrYt.)
<br />February 26, 1952.
<br />OTHER 0 Nursing Home/LTC
<br />0 Decedents Home
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10b. NAME OF SPOUSE (E(rat;' Middle, Last, Suffix) if wle, give maiden mute
<br />Alvin Gosda
<br />14a. IN FORMANT•$A. IgE
<br />Alvin Gosda
<br />16a. EMBALMER -SIGNATURE'
<br />Kelley D Sheridan
<br />12, MOTHERS -NAME (First, Middle, Malden Surname)
<br />Roberta Rogan
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Grand Island City Cemetery
<br />17a. FUNERAL HOME., NAME AND MA LING ADDRESS (Street, City or Town.,State)
<br />Ail FaithsFuneral Home, 2929 S. Locust Street, Grand Islands Nebraska
<br />CAUSE OF DEATH (Sid
<br />16b. LICENSE NO.
<br />1439
<br />CITY l TOWN
<br />Grand Island
<br />Instructions and examples)
<br />18. PART 1. Enter RAs Chain of events- diseases, injures,: or complications -that directly caused the deeth.DO NOT enter teneinal events such as cardiac arrest, -.
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE (Final
<br />disease ettoadltion f9auItiog
<br />Indteetmj
<br />Sequentially let conditions, it
<br />any, leading 16 the mum Hated
<br />Ener the uNDE$I PING CAtU*E
<br />idixea$q or injury that (nitlaied
<br />the events tette ng in death)
<br />LAST
<br />IMMEDIATE CAUSE:
<br />a) chronic hypoxic hypercapnic respiratory failure due to chronic chronic interstitial lung
<br />disease
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)dermatomyositis with respiratory involvement
<br />DUE TO, QR AS A CONSEQUENCE OF:
<br />c)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />E sir
<br />14b. RELATIONSHIP TO.PEGEDENT'
<br />Spouse.
<br />16c. DATE(M°., Day, Yr.)
<br />September 6,;2023
<br />STATE
<br />Nebraska
<br />:1710. Zip. Code..:::
<br />68801
<br />onaet to death
<br />9 Years
<br />18. PART It. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but net resu t ng tai the underlying cause given in PART 1.
<br />hypertenston,,putmonary hypertension, history of prior pulmonary embolism
<br />211. IF FEMALEt:
<br />Not pregnant within past;yaer
<br />❑ Pregnant 81 time otdeatk
<br />Not pregnant. but Pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />❑ Unknown: pregra rel within the past year
<br />22a. DATE OF:11siJURY (MO, Day, Yr.)
<br />22d. INJURY AT WORK?
<br />❑YES
<br />ONO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Hornlclde
<br />❑ Accident © Pending Mtvsstipation
<br />o Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF INJU
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />225LOCATION ;OF INJURY:, STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />September 2, 2023
<br />2110, IF TRANSPORTATION INJURY
<br />❑ pever/operator
<br />0 Passenger
<br />0 Pedestrian
<br />❑
<br />Other (specify)
<br />19. WAS M M. EXAMINSiR
<br />OR CORONER CONTACTED?'
<br />❑ YES IRI NO
<br />21r . WAS AN AUTOPSY PERFORMED?
<br />YES (i .NQ
<br />21d. WERE AUTOPSY F NDINGS AVAULAi9La
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YES ❑ NO
<br />farm, street, factory, office building, construction sth
<br />Ote- (Spe01*1
<br />CITY/TOWN
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />September 12, 2023
<br />23c. TIME OF DEATH
<br />03:16 AM
<br />the bast ot:my knowledge, death occurred at the time, date and place
<br />and due to thd:iause(s) stated. (Signature and Title)
<br />even Husen, MD
<br />Steven Husen, MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska, 68803
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />;:29PCODE
<br />24b. TIME OF DEATH
<br />24d. TIME PRONOUNCED DEAD
<br />E4. 0n the tiaeIe of examination and/or investigation, In my opinteedfie 1 trtxur ieiet.
<br />tiw time, date and place and due to the cause(s)stated. (Signature eeirrale)
<br />I 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑YES [ONO
<br />26. DID TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />❑ YES ;El NO iQ PROBABLY 0 UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO ❑ YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br />September 21, 2023
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