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z LL 9 a w •c a 43 a a U a O I^ STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTMIAN.Q�H,UMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NES� P�1RTM�IVT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITARY Pe 1 f� " DATE OF ISSUANCE �SANLEY'.. QPFt c:, y SEP 2 5 2008 20081,0375 ¢' 24� LINCOLN, NEBRASKA �, , VumAl11 SET�V CFS . rh STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HJMA�V l ?� � W Vr9 . ,R P CERTIFICATE L 1. pECEDENT'S -NAME (First, Middle, Last, Suffix) 2. S §X 3. A E;OIeD (Mo.,Day.Yr:) Mildred Elsie Gulzow Female S ' t6mber'17i 2008 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Be. AGE -Leal Birthday 6b,UNDER 1 YEAR Be. UNDER 1 DAY B. DATE OF BIRTH (Mo., Day, Yr.) (yra.) MOS. DAYS HOURS MINS. ' Grand Island Nebraska 87 June 3, 1921 7. SOCIAL SECURITY NUMBER Be. PLACE OF DEATH z 506 -68 -1194 WOSPITAL: ® Inpatient O1HE8: ❑ Nursing Home/LTC [] ER/Outpatient ❑ Decedent's Home ❑ Hospice Facility bb. FACILITY -NAME (if not Institution, y:ya street and number) Saint Francis Medical Center ❑ DOA ❑Other(Specify) IMMEDIATE CAUSE: Be, CITY OR TOWN OF DEATH (Include ZIp.Cods) THall 84. COUNTY OF DEATH IMMEDIATE CAUSE (Final 1 disease or condition resulting a)�. Grand Island 68803 m In death) t t1---^- �.1..--- •___,..�,^....^^-+,,,,, Ss. RESIDENCE -STATE Sb. COUNTY Sc. CITY OR TOWN me Nebraska Hall Grand Island gd. STREET AND NUMBER go. APT. NO. of. ZIP CODE 99. INSIDE CITY LIMITS 6651 N. Skypark Rd. 1 I 68801 ❑ Yes ® No 10a. MARITAL STATUS AT TIME OF DEATH Ig Married ❑ Never Married lob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name. 249. On the basis of examination and/or Investigation. In my opinion death occurred ❑ Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown Lester L Gulzow O 11. FATHER'S -NAME (First, Middle, Last, Suffix) 12. MOTHER'S -NAME (First, Middle, Malden Surname) Joseph Niemoth Minnie Gosda 13, EVER IN U,S, ARMED FORCES7 Give dates of sarvics if Yes. 14a. INFORMANT -NAME 14b. RELATIONSHIP TO DECEDENT (Yes, No, or Unit.) No Lester Gulzow Husband 20. IF FEMALE: 16. METHOD OF DISPOSITION 18 MB 'LMER- SIGNATUR 18b. LICENSE NO. �%' 18c. DATE (Mo., Day, Yr.) Natural ❑ Homicide ❑ Driver /Operator 9 September 22, 2008 0 Passenger ❑r�t Pedestrian � �" a T ©Cranudien ❑Entombment 0 Ram evel 00ther(apecity) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITYITOWN STATE ❑Unknown If pregnant within the poet year Westlawn Memorial Park Cemetery Grand Island Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b, Zip Code 1 All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801 onsat to death �'iQu,r c -onset to death I onset I I 'onset to death I I 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 91 NO 21c. WAS AN AUTOPSY PERFORMED7 ❑ YES JklO 21d, WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO h7 /� 9 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 1 22c, PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) U It 22d. INJURY AT WORK? 721. DESCRIAE HOIN IN.IURY OCCURRED ~ ❑ YES ❑ NO i 221. LOCATION OF INJURY - STREET 6 NUMBER, APT. NO, CITY/TOWN STATE zip CODE CAUSE OF DEATH (Sea Instructions and examples z 1 . ART I. Enl*( the ctnra'ot evanL . pi�peNe, InjurPp, er aempllepllpne -that din "y Aeuepd lIN depth. Dp NO pntpr terminal ewnU pupn "ee card lac accept, ag rpeplmlery mss, nr ventricular Iibriin 1- without Wwwing the mlology. DO NOT ABBREVIATE. Enter Only Ong Cau8a on A Ilea. Add Additional line it ma svafy. IMMEDIATE CAUSE: U IMMEDIATE CAUSE (Final 1 disease or condition resulting a)�. m In death) t t1---^- �.1..--- •___,..�,^....^^-+,,,,, „•,,,,- 24c. PRONOUNCED DEAD (Mo., Day, Yr.) DUE TO, OR AS A CONSEOU CE OF: me Sequentially list conditions, If L a I ` b) 1 ` L any, leading to the cause listed r, a))z .. 0Y� S 1_I, V^'I7rK•J�LXrI�'1 LC On line a. DUE TO, OR AS A CONSEQUENCE OF: t 1 Enter the UNDERLYING CAUSE c) y 23d. To the beat of my knowledge, death occurred at the time, data and place (disease or Injury that Initiated 249. On the basis of examination and/or Investigation. In my opinion death occurred y the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: O at the time, date and place and due to the cause(s) stated. (Signature and Title) LAST d) 18. PART [L OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting In the underlying cause given In PART I. K 1 1l K (-696r W 20. IF FEMALE: 21 a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUF LL LL of pregnant within past year Natural ❑ Homicide ❑ Driver /Operator U Pregnant a! time of death ❑ Not pregnant, but pregnant within 42 days of death ❑ Accident © Pending Investigation ❑ Suicide ❑Could net be determined 0 Passenger ❑r�t Pedestrian � �" a T ❑ Not pregnant, but pregnant 43 days to 1 year before death 0 Other (Specify) ❑Unknown If pregnant within the poet year a onsat to death �'iQu,r c -onset to death I onset I I 'onset to death I I 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 91 NO 21c. WAS AN AUTOPSY PERFORMED7 ❑ YES JklO 21d, WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO h7 /� 9 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 1 22c, PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) U It 22d. INJURY AT WORK? 721. DESCRIAE HOIN IN.IURY OCCURRED ~ ❑ YES ❑ NO i 221. LOCATION OF INJURY - STREET 6 NUMBER, APT. NO, CITY/TOWN STATE zip CODE 28. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a, HAS ORGAN OR TISSUE ONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES NO ❑PROBABLY ❑ UNKNOWN ❑YES NO Not Applicable If 2ga Is NO ❑YES NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Kimberly Mickels, M.D., 729 N. Custer Ave., Grand Island, NE 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) SEP 2 4 2008 IV 23a. DATE OF DEATH (Mo., Day, Yr.) z 24a. DATE SIGNED (Mo.. Day, Yr.) 24b. TIME OF DEATH ag September 17, 2008 U �Rt m 23b. ATE SIGNED (Mo, Day, Yr.) � 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD me 10:15 P.m O o m g �aa y 23d. To the beat of my knowledge, death occurred at the time, data and place 249. On the basis of examination and/or Investigation. In my opinion death occurred y and dine to the causes) staled. (Signature and Title) O at the time, date and place and due to the cause(s) stated. (Signature and Title) cQi 0 28. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a, HAS ORGAN OR TISSUE ONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED? ❑ YES NO ❑PROBABLY ❑ UNKNOWN ❑YES NO Not Applicable If 2ga Is NO ❑YES NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) Kimberly Mickels, M.D., 729 N. Custer Ave., Grand Island, NE 68803 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) SEP 2 4 2008 IV