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WHEN THIS COPY CARRE:S THE RAISED SEAL OF THE NEBRASKA HEALT_t SYS7E'IY~ fT CERTE:IES T~ BELOW TO BE A TRUE COPY OF THE ORIf~iNAl THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITA~`1' THE LE(aAL DEPOSITORY FOR VITAL RECORDS. - ~~~~" _ ` fi=r HI,IMAN SERVICES ~~JV FILE WITH ~lHhl. WHICH /S DATE OF ISSUANCE 2 p Q 9 ~ ~ ~ ~ 4 ~ * ~- - = -- '"~ •~~° • ~ODPER MAR 3 x 1999 _ ~_=~~Sd4'~3fiANT SfiAT~~ISTRAR LINCOLN, NEBRASKA HEi4L~AlIKi1 ~MAIIl.~E'f.~illSYSTEM STATE OF NF9RASKA- bEPARTME~C OP HEALTH AND~{ElM+~•i?'WAN~AND SUPPORT' VITAL STATISTIC:=•w~=' T" --` - - CERTIFICATE OF D'ES"`:".~:= i. DECEDENT • NAME FIRST MIDDLE LAST 2; ~SFX" 3. PATE OP DEATH /MOnlh pay. Year/ Marjorie A. Goosic Female March 17, 1999 4. CITY AND STAVE OF BIRTH IN Mf in US.A.. name cpunlry/ 5a. AOE • Laat Birthday UNDER 1 YEAR UNDER 1 DAY 8. DATE OF 81RTH !Mandl. Rey. Yen) Grand Island, Nebraska IY'S.'68 sbMOS I DAYS ScHOUgs MINS Novembex 6, 1930 7. SOCIAL SECURTIY NUMBER 8a. PLACE OF pEATH 508-28-7794 HOS_PI_TAL: © InpatiaM OTHER: ^ Nursing HOme Bb. FACILITY • Nsme ldlrol inaalwron, give street and nuntbKl ^ ER Outpeaarn ^ Raaldance Saint Francis Medical Center ^ °DA ^ ah.rrsaecr"' Bo CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS Be. COUNTY OF DEATH Grand-...Island Yea ®~ ^ Hall 9a. RESIDENGE • STATE Db COUNTY gt. CITY, TOWN OR LOCATION id. SYREET AND NUMBER rlncltfaalgz~c CaWI 68803 ~' INSIDE CITY LIMITS Nebraska Hall Grand Island 4203 W. Ca ital Ave . Yee [~ ND ^ t D. RACE • le.q., Wnne Black. Amencan Inbian. t 1, ANCESTRY le.g.. Mllsn. Mazican, parman, etc! 12. ©MARRIED ^ wIpOWED 13. NAME OF SPOUSE /d wde. piw ma/dsn nab) etc.llSDeclMl White Ispac'NI American NEVER DIVORCED Verlon Goosic 14a. USUAL OCCUPATION lGwe kind M work done dwrng md5f 146 KIND OF BUSINESS INDUSTRY 15. EpUCATION (Specify only nt Met grade cpmphrtadl al worklrrg tile, even it redredl Ebme to or Secondary lD-121 Collage ll-4 or 5•I Sales Clerk Various Retail Sales 12t~T Grade T _ ~ 18. FATHER - NgME FIRST MIDDLE LAST 1 Z MOTHER FIRST MIDDLE MAIDEN SURNAME Chaxles NMN Johnson Marie NMN Nelson • 18. WAS DECEASED EVER IN U.S. ARMED FORCES 19d. INFORMANT -NAME (Yes. no ~r unk.l lu yes gwe wer a~C dates Ct 5e:v;Casl No ------- , Verlon Goosic -~ Husband _ 196. INFORMANT MAILING ADDRESS (STREET OR R.h p. NO.. CITY OR TOWN. STATE. ZIP) 4203 W. Capital Ave. , Grand Island Ne. 68803 ___,__,_,_. ~ ~ 20 EMBALMER -SIGNATURE 8 LICENSE NO 21 e. METHOD OF DISPOSITION 21 b. RATE 21 c. CEMETERY OR CREMATORY ~ NAME Not Embalmed ^euriel ^RempYal Mar. 18, 1999 Central Ne. Cremation Serv _ 22d. KUNERAL HOME -NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston-Sondermann F.H. 99h FI INFRA( HOMF ADf1RFSC ISY RFFT OA R f D NO !:ITV OR TOWN X^cremation ^D°""'°^ RTATF 71P1 Gibbon, Nebraska_ 601 N. Webb Road, Grand Island, Ne. fi$803-4050 _ _ 2~9.` IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lat. Ibl, AND Icp t Imerval Mtween Ansel and deem yPART ~ n ' •~ lj~9n~~~a ~~ I lal ~Q /~dra,Pu(~oagry ,/ rQ ~~'~~ ....-., i Im~val 6elwaen pnael end dealn DUE TO, OR AS A CONSEOUENGE OF I Iw ~~la~ ~I~tnC~ior~ aid" ~I19larygrq l'k,hvllty ~ _~•~ ~_~<~f _ DUE TO. OR AS A CONSEO NCE OF' I (marvel n Onset antl tleatn ICI ~/ •'•` 1r, `•- rmr• -• 1./, "- - - L•ld ~JL LLGLLIL l G Ull [LLLVWII I OTHER SIGNIFICANT CONDITIONS ~ Conditions contributing 1o the death bW rlpt relatetl PART III IF FEMALE. wA5 THERE A 24 AUTOPSY 25. WA5 CASE REFERRER TO MEDICAL PART II PREGNANCY IN THE PAST 3 MONTHS ,`.- EXAMINER OR CORONER? (Agee 10.541 Ves ND Ves Np Vea Nb 26a 28h. OAYE OF INJURY /Mn.. Day Yr./ 28c. HOUR OF INJURY 26d. DESCRIBE HOw INJURY OCCURRED Accident ~ Undetermined M Suicide ~ Wending 25e. INJURY AY WORK 261 PLACE QF INJURY • t Mfr, .farm, street. ractpry l i t S f tl; 25g. LOCATION STREET OR R.F p NO. CITY OR TOWN STATE ^ Hommide Invesnganon ^ ^ Yea No ng. e c. / pecry v ce bui C 27a. DATE OF pEATH IMP. Pay Yr.J 28a. PATE SIGNED /Mp. Day. Yr,) 286 TIME OF DEATH h- 3-I7~9`~ ,~a ~sx[ M ~ 27h. DAYS SIGNED rMp. Day. Yr; 27C YIME OF DEATH r ~ ~ 28C. PRONOUNCED DEAD /Mo.. Day, Yc/ 28d. PRONOUNCED DEAR /Fburl r ~'f .Y ~~ QG ~ 4~ ~ - ~~~ ~! ~ .... yri.~ M .. .. .. . M death curved at ale b data antl lace aM due to the o the at o my wledge ~ On the basis of azamination r inv ugatgn, m my opnwn tleath occurred et ° ~ 2tla ~ . , I selsl Stated ~ . v is the time. Cab anC pl e a du auaelsl shad. I , I ~ nature antl Tale ~~ ~~j - ~~ I ., ,.. St nature end Titk 29 Dlp TOBACCO USE CONTRIBUTE TO YHE pEgTH7 / 3p.~/I-IAS ORGAN OR TISSUE DONATION BEEN CONSIDERED 30.D WA C NSENT GRANTED? ^ YES ~ NO ^ UNKNOWN ^ ^ YES ~ NO ~ ^ YES ~ NO ANA ADDRESS O F CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COVNTV ATTORNEY( 31 NAME !Type wPnntl _ / .~ Gar L, st? f f ~ ~. Z Wl ~qr Gr~cn ' ~S~qn~ !~L' ~~~jOj 32a. REGISTRAR 32b. DATE FILED BV REGISTRAR /MO., pdy. Yr./ MAR 2 21999 _- v -