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<br /> STATE OF NEBRASKA
<br />
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTH. AND HUMAN SERVICES, IT CERTIFIES
<br /> THE BELOW 70 BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEORAS ~R q~TkENTIOF (HEALTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY F(~R UI~ V RECORDS."
<br /> DATE OF ISSUANCE
<br /> A by q 2 TANII~S.uGOO
<br /> APR PFR"
<br /> 2 2009 ~4I57)AN~67ATE REGISTRAR
<br /> 2 41 LINCOLN, NEBRASKA - O oq 0 III ,kAN,SERV ~E5 'HEALTH 9Np,
<br /> STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPO
<br /> -0
<br /> CERTIFICATE OF DEATH 9;
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX DATE UFDEATH (Mo.,Day, YrJ
<br /> Mary Lou Goodman Female April 17, 2009
<br /> _ 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 5b. UNDER i YEAR 5c. UNDER 1 DAY 6, DATE OF BIRTH (Mo., Day, Yr.) -
<br /> (Yrs.) MOS. DAYS HOURS MIN3.
<br /> Fullerton, NE. 81 _ _ arch 16, 1928
<br /> 7. SOCIAL SECURITY NUMBER Be, PLACE OFOFATH- - ~W
<br /> 508-28-7783 HOSPITAL: MInpatient OIHE(t ❑ Nursing Home/LTC ❑ Hospice Facility
<br /> Bb. FACILITY-NAME (If not Institution, give street and number)
<br /> ❑ ERIOu1pa11en1 Cl Decedent's Home
<br /> St. Francis Med. Center ❑ Dm ❑Other(Spec9y)
<br /> Bc. CITY OR TOWN OF DEATH (include Zip Coda) Bd. COUNTY OF DEATH
<br /> Grand Island 63803, Hall
<br /> 9a. RESIDENCE•STATE fib. COUNTY tic. CITY OR TOWN
<br /> Nebraska Hall Grand Island
<br /> 9d. STREET AND NUMBER 9e. APT. NO 91. ZIP CODE 99. INSIDE CITY LIMITS
<br /> 2419 W. Anna 68803 YES ❑ NQ
<br /> 10a. MARITAL STATUS AT TIME OF DEATH (IMarrled ❑ Never Married 10b. NAME OF SPOUSE (Fliet, Middle, Last, Suffix) If wife, give maiden name.
<br /> El Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown
<br /> Lowell Goodman
<br /> 11. FATHER'S-NAME (First, Middle, Last. Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Max L. Wozniak Marie Raftery.
<br /> 13. EVER IN U.S, ARMED FORCES? Give dales of service If yes. 14a.INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br /> (Yas,no,orunk.) NO Lowell Goodman Husband
<br /> 15. METHOD OF DISPOSITION 19a. EMBALMER-SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr. )
<br /> El Burial ❑Donation Not Embalmed
<br /> April _
<br /> NCremalion ❑ Entombment 16d, CEMETERY, CREMATORY OR OTHER LOCATION CITY! TOWN STATE
<br /> ❑ Removal ❑ Other (Specify)
<br /> estlawn Memorial. Park Crematory Grand Island, Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Streel, City or Town, Slate) 17b. Zip Code
<br /> Livin ston--Sondermann Funeral Home 601 N. Webb Road Grand Island NE. 68803
<br /> NONNI=
<br /> r/(ta. PART I. Enter the WuW1Ql events--diseases, Injuries, or complications.-that directly caused the death. DO NOT enter terminal events such as cardiac arrest, kAPPROXIMATE INTERVAL
<br /> respiratory arre6l, or ventricular 116r111011on without showing the etiology. DO NOT ABBREVIATE. Enter only one Ceu66 on a line. Add additional lines if necessary. I
<br /> C IMMEDIATE CAUSE: I onset to death
<br /> IMMEDIATE CAUSE (Final (a)
<br /> disease or condlWon resulting DUE TO, OR AS A CONSEQUENCE OF:
<br /> Indeeth) I onset to death
<br /> Sequentially list conditions, It M I r `--w~
<br /> any, leading to thacauw listed DUE TO, OR AS A CONSEQUENCE OF: I onset to death
<br /> on line e.
<br /> Enter the UNDERLYING CAUSE
<br /> (disease orlnjury that Initiated (c) I
<br /> ft events resulting In death) DUE T0, OR AS A CONSEQUENCE OF: I onset to death
<br /> LAST
<br /> I
<br /> I
<br /> 1W, PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting In the underlying cause given In PART I. Q19. WAS MEDICAL EXAMINER
<br /> OR CORONER CONTACTED?
<br /> _ ❑ YES 0,NO
<br /> 9. IF FEMALE: 1a. MANNER OF DEATH 21b.IFTRANSPORTATION INJURY 1c. WAS AN AUTOPSY PERFORMED?
<br /> 10 Not pregnant within past year ®Nalural ❑ Homicide O Driver/Operator
<br /> ❑ Pregnant at time of death Q Accidenl❑ Pending Investigation ❑ Passenger El YES &NO
<br /> ❑ Not pregnant, but pregnant within 42 days of death O Suicide ❑ Could not be determined Ell Pedestrian 21 it. WERE AUTOPSY FINDINGS AVAILABLE TO
<br /> ❑ Not pregnant, but pregnant 43 days to 1 year before death ❑ Other (Specify) COMPLETE CAUSE OF DEATH?
<br /> ❑ Unknown If pregnant within the past year ❑ YES ❑ NO
<br /> A 22a. DATE OF INJURY (Me., Day, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site. etc. (Specify)
<br /> 6, I m
<br /> rd.
<br /> 22d. INJURY AT WORK? Zen. DESCRIBE HOWtNJURYOCCURREU ~
<br /> ❑ YES ❑ NO
<br /> r
<br /> 221. LOCATION OF INJURY -STREET&NUMBER,APT,NO, CRYITOWN STATE ZIP CODE
<br /> NY
<br /> 3a. DATE OF DEATH (Mo., Day, Yr.) = 24a, DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> w, Z
<br /> ( a Aril 17,- 2009 'd% m
<br /> 3b. DATE SIGNED (Mo., Day, Yr.) 30. TIME tlF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> -4- 1"1-0 9:20 a.m m
<br /> tag
<br /> u u
<br /> 3d. To the beet of my knowledge, death occurred al the lime, dale and place ~ 24s. On the basis of examination andlor investigation, In my opinion death occurred at
<br /> a0p due to the cause(s) stated, (Signature and Title) ♦ the time, data and place and due to the cause(s) slated. (Signature and Title)
<br /> \ 8
<br /> i 5. DID TOBACCO USE CONTRIBUTE TOTHE DEATH? e. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? Bb. WAS CONSENT GRANTED?
<br /> X YES ❑ NO ❑ PROBABLY ❑ UNKNOWN ❑ YES 5,NO Not Applicable It 25a is NO ❑ YES ❑ NO
<br /> ' 27, NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pri
<br /> ,Zzj- Ox 1/- rvltav S 1,44 N C a er A". 0 4.4 ntc,.n4 /U(5 &S~,v 3
<br /> 28a. REGISTRAR'S SIGNATURE
<br /> 464w. 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> (r ,.APR 2 0 zoos
<br /> HHS-61 11/03 (55061)
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