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WHEN TINS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND= SEfrACES <br />SYSTEM, IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REM WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STA>WH/Qil -IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - <br />DATE OF ISSUANCE ^= - <br />, ANLEY S :. R ' <br />3/2/2004 �i 0,40 3 ®d &*51 A r��i E*X »fi <br />LINCOLN, NEBRASKA HEAL TI i �SERPRMS S S €l <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERIES ft"NCKA D�RT <br />VITAL STATISTICS 4 02229 <br />CERTIFICATE OF DEATH - L <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2 SEX - <br />,3, DATE OF DEATH /Month. Day. Year/ <br />Dorothy Clara Gudgel <br />Female <br />February 26, 2004 <br />4. CITY AND STATE OF BIRTH /llnot in USA. new counbyl <br />5a. AGE - Last Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />8. DATE OF BIRTH / Month. Day. Year) <br />Curtis, Nebraska <br />(Yrs.) 85 Sb.MOS. <br />January 31, 1919 <br />atvs <br />5c. HOURS MINS. <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />521-20-9669 <br />HosPrrAL ❑ Inpatieia OTHER: ® Nursing Home <br />❑ ER Outpatient ❑ Residence <br />Bb. FACILITY -Name flfnot insk'fuNart Ova skeet and number) <br />Wedgewood Care Center <br />❑ DOA ❑ Other(Swty) <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />6d. INSIDE CITY LIMITS <br />8e. COUNTY OF DEATH <br />Grand Island <br />yes X❑ No ❑ <br />Hall <br />9a. RESIDENCE -STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER /Including Z)p Codel <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand IS <br />309 E.21 St. 68801 <br />Yes It No ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />11, ANCESTRY le.g- Milan. Mexican. Berman, etc) <br />12 ® MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE (k wire. give maiden name) <br />ete)(Swity) White <br />(SWIM American <br />NEVER DIVORCED <br />MARRIED <br />Andrew Gudgel <br />14a. USUAL OCCUPATION (Give kmdof work cane dunnp mast 14b. <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Speciy only highest grade completed) <br />Elementa1 ry (0 -12) - College 11-4 or 5 -1 <br />of working life. even it reeiredl <br />Homemaker <br />Own Home <br />orSecondary <br />16. FATHER -NAME FIRST MIDDLE LAST 17. <br />MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Frank Floro <br />Laura Ellen Morgan <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT -NAME <br />(Yes, no, or unk.) (d yes. give war and dates of serviced <br />Andrew Gudgel <br />No <br />19b. INFORMANT MAIU14G ADDRESS 1STREET OR R.F.D. NO., CITY OR TOWN. STATE. ZIP) <br />309 E. 21st. Ste Grand Island, Nebraska 68801 <br />20. SALMER - SIGNATURE 8 UCEN 0. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE - 21 <br />c. CEMETERY OR CREMATORY - NAME <br />#1071 <br />5j]&.w - ❑Removal <br />March 11,2004 <br />Mount Hope Cemetery <br />a. FUNERAL HOME - NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />All Faiths Funeral Home <br />El Chardon ❑Do... <br />Springview, Nebraska <br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) <br />2929 S. Locust St., Grand Island, Nebraska 68801 <br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. (b), AND (c)) I Interval between onset and death <br />PART <br />(a) I <br />DUE TO, OR AS A CONSEQUENCE OF 1 Irtlerval between onset and death <br />I <br />I <br />(b) <br />DUE TO, OR AS A CONSEQUENCE OF: Interval between onset and death <br />I <br />I <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions tl1e death but not related P ART <br />111 IF FEMALE WAS THERE A 24 <br />AUTOPSY <br />25, WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />IN THE PAST 3 MONTHS? <br />EXAMINER OR CORONER? <br />(Ages <br />10 -U) Yes 11 No <br />Yes No <br />Yes No <br />26a. <br />26b. DATE OF INJURY 1W.. Day Yr./ <br />26c. HOUR OF INJURY <br />261 DESCRIBE HOW IN�JRY OCCURRED <br />F-1 Accident [] Undetermined <br />I M <br />❑ Suicide 7 Pending <br />26e. INJURY AT WORK <br />26f. P t F INJUdcRY fho>re, farm, street. factory <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />yes ❑ No 11 <br />% �l'� <br />I <br />' <br />27a. DATE OF DEATH f lb.. Day. Yr.) <br />28a DATE SIGNED fMO.. Day. Yr) <br />28b. TIME OF DEATH <br />February 26, 2004 <br />M <br />a< <br />27b. DATE SIGNED fMa. Day. Yr) <br />27c. TIME OF DEATH <br />g <br />� � r <br />28c. PRONOUNCED DEAD /Mo.. Day, Yrl <br />28d. PRONOUNCED DEAD (Hour) <br />a <br />y <br />a� <br />February 27,2004 <br />12:40 A.M <br />s¢5F <br />M <br />27d. To the best of my knowledge. death occurred M tfte tlme, date and piece and due to the <br />~ � 28e. On the basis d examination a+10,or investigation, in my opinion death occurred at <br />a <br />causels) stated. <br />c4 the time. date and place and due to the cause(s) stated. <br />- <br />4 <br />(Signature and Title) ► <br />jol(Signature and Title) ► <br />29. DID TOBACCO USE CONTRIB THE DEATH? 30a <br />HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b <br />WAS CONSENT GRANTED? <br />❑ YES NO ❑ UNKNOWN <br />❑ YES PIN <br />❑ YES ✓�NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICM OR COUNTY ATTORNEY) /Type or Prim) <br />Jane McDonald, M.D., 80 Alpha, G nd Island, Nebraska 68803 <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR fMo., Day. Yr.) <br />1 <br />