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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL pF THE NEBRASKA DEPARTMENT pF HEALTH "f~'L?NI~li~l, ERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA~'1~7CN~~M,bI~ HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY EOR.1dIT~L~ GORe'~S. •`' ~;~, ~ r)
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<br />DATE OF ISSUANCE _ ~
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<br />201000953 ~~~~~~ ~ • : ,w, ,~A
<br />11/19/2009 ;~~.~STAN ~~E~I~E~ISTRA~~ ,
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<br />LINCOLN, NEBRASKA li~J'~i~', VdC'~$~ ,y' ,r•~
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<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SER~CE$'y,••, ~'~wt ~ ~~ ;~09 02578
<br />CERTIFICATE OF DEATH ' ~ ~ , 4S'~• n~ • • • ~ - •: .,..
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX ~~
<br />~ T80)F ~ (Mo.; Day, Yr.)
<br /> Andrew Jessie Gudgel Male
<br />' •'~JVd~rn~ter ~; 20D9
<br /> 4. CITY ANp STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE -Last Birthday 6. UNDER 1 YEAR 5c. UNDER 1 DAY e: DATE!AF SIRT.fj (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINE.
<br /> Wrage, Nebraska 91 November 5,'1918
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE pF pEATH
<br /> 508-44-8290 H9SPITAL ^ Inpatient OTHER ®Nursing Home/LTC ^ Hospice Facility
<br /> Bb. FACILITY-NAME (If not Institution, glue aVeet and number) ^ ER/Outpatlent ^ Decedent's Home
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<br />
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<br />Tiffany Square Care Center DOA Other (Specify)
<br />© ^
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<br />w _ _ __
<br />Bc. CITY OR TOWN OF DEATH (Include Zlp Coda)
<br />8ti. C4UN7Y OF DEATH
<br />o Grand Island 68803 Hall
<br />"I 9a. RESIDENCE•STATE 96. COUNTY 8c. CITY OR TOWN
<br />x
<br />Nebraska
<br />Hall
<br />Grand Island
<br />LL 9d. STREET AND NUMBER 9a. APT, NO. 9f. ZIP COpE 9g. INSIDE CITY LIMITS
<br />;; 309 E. 21st St. 68801 ®YES ^ NO
<br /> t0a. MARITAL STATUS AT TIME pF pEATH ^ Married ^ Never Married 106. NAME pF SPOUSE (First, Middle, Laet, SUflix) I} wife, glue maiden name
<br />!~ ^ Married, but separated ®Widowad ^ Divorced ^ Unknown pprothy Floro
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<br />11. FATHER'S-NAME (First, Middle, Last, Suffix)
<br />12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Amos Gudgel Emily Ogden
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<br />E 13. EVER IN u.S. ARMEp FORGES? Glva dates pf service Ii Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
<br />~ (Yes, No, or ur,k.) Np Ruth Ellen Strauch Daughter
<br />~ 15. METHOD OF DISPOSITION 18a. EMBALMERSIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br />I°- ®Bunal ^ Donation paniel p Naranjo 1071 November 11, 2009
<br /> ^ Crematlpn ^ Entpmbment
<br /> 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
<br /> ^ Removal ^ Other (SpacKy)
<br /> Springview Cemetery Springview Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clly or Town, State) 17b. Zlp Coda
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> AU E F DEATH See instruct ohs an exam es
<br /> 1B. PART I. Enter the chain vi avanta--dlsaasea, Injuries, or complicatlona-that directly puaed the death. DO NOT enter terminal events such as CArdlac ari'9st, APPROXIMATE INTERVAL
<br /> respiratory arrest, yr ventricular Obrtllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one Cause on a Ilne. Add additional Iinea if ne60aaary.
<br /> IMMEDIATE CAUSE: onset to death
<br /> IMMEDIATE CAUSE (Final a)Myeloproliferative Disease ;Years
<br /> tliseaw orcontlidtln nwntNg - _.--------- - -- ._ .._~. _..~ _. , _ . ~..
<br /> In death) DUE TO, OR AS A CONSEQUENGE OF: onset to death
<br /> Saquantlally IlBt Condillona, If h)Anemia :Years
<br /> any, leading to the CdueB listed
<br /> on Iina a.
<br />pUE TO, OR A5 A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (dlaeaae or Injury that Initiated
<br /> the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: onset tp death
<br /> LAST d)
<br /> 18. PART II.OTHER SIGNIFICANT GONpITIONS-Gonditlons contrlbutlnp to the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
<br /> Coronary Artery DiSeaBe OR CORONER CONTACTED?
<br />~ ^YES ®NO
<br />w 20. IF FEMALE: 21 a. MANNER OF DEATH 21b. IF TRANSPORTATION INJUR 21c. WAS AN AUTOPSY PERFORMED?
<br /> ^ Not pregnant wlthln past year ®Natural ^ Homicide ^ DdverlOperator
<br /> ^ ~rES ® NO
<br />~ ^ Pregnant at time of death ^ Accident ^ pending Investigation ^ Faaaanger
<br />7,
<br />~ ^ Not prepnan4 bul pregnant wlthln 42 days Of death
<br />^ Suicide ^ Could not be determined ^ Pedaatdan 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />
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<br />^ Not pregnam, but pregnant 49 pays to t year before death
<br />^ lhhar (Specify) Tp COMPLETE CAUSE OF pEATH?
<br />4 ^ Unknown If pregnant whhln the past year ^YES ^ NO
<br />
<br />a 22a. DATE OF INJURY (Mo., Day, Yr.) 226. TIME OF INJURY 22c. PLACH OF INJURY-At home, farm, street, factory, office 6ullding, construction site, etc. (Specify)
<br />
<br /> 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY pCCURRED
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<br />^YES ^ NO
<br /> 22f. LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYITOWN STATE ZIP GODE
<br /> 23a. DATE OF DEATH (Ma., Dey, Yr.)
<br />b
<br />6
<br />2009
<br />~ W N 24a. GATE SIGNED (MV., Day, Yr.) 24b. TIME OF DEATH
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<br /> r 23b. DATE SIGNED (MO., Pay, YrJ 23c. TIME OF DEATH ~' ~
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> e ~ Z November 10, 2009 08:20 PM
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<br /> 3d, 7p the beat of my knowledge, death occurred at the time, data and place
<br />g and due tv the Causelal stated. (51 nature and TRIe)
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<br />~ w ~ 948. On the 6asle of aXaminapon andPor InveMigatlon, in my opinion death occurred at
<br />~ p the time, date and place and due to the cauae(a) elated. (Signature and TRIe)
<br /> o
<br />~ ~ Jane A. McDonald, MD a
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<br /> 25. Alp TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION SEEN CONSIDER@p? 28b. WA5 CONSENT GRANTED?
<br /> ^ YES ^ NO ^ PROBA9LY ® UNKNOWN ^YES ®NO Not Appllca6le If 28a Is Np ~ YES ^ Np
<br /> I A I A A I AN N I ype or r n
<br /> Jane A. McDonald, MD, 800 N Alpha Street, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 286. DATE FILED BY REGISTRAR (Mp., Day, Yr.)
<br /> November 12, 2009
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