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STATE OF NEBRASKA
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEALTK_AAID HUMRM S�RVICES, lT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE Wl7"H THE NEBRASlCA DF-�.,�4R7"M�'I�iT OF IJlEALTH AND
<br />HUMAN SERVICES, VI7"AL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR 1"l.iT,��L ��CG7 .. ' �,
<br />��'ji ',
<br />DATE OF ISSUANCE ������I�� t J, �.1 °��!', " ..
<br />ST�I f�IL�'Y S ,.�O,BP�R � , �� � ;•'
<br />�A� ���o�� � o�.10 � o o� D� AQ�TM lUT 4 HEACT AI1�D Y f
<br />LINCOLN, NEBRASKA H(jM��E, VICES """ "
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<br />L�TATG AC \IG��AQV• 11C���T�IC\R /1C ItL�At TIJ 1►tA Ltl 1���\t l�C�tA/�CC'� � � �E ' �' ' Y1� n^�I �C�� �
<br />...... _ _. .._.........0 � CATE OF EAT . ...,....-... ..�.. ., , J. .0 � L U 3 .f. �
<br />1. DECEOEJdT"SNAMH (Fltst,. Asidme, L�t, 9utfit) ' 2 SEJf 3. OATE OF DFATH (AAo.,Day,Yr.)
<br />`�
<br />David Lee Goosic Male January 16, 2011
<br />\ 4. CITY AND STATE OR TERRITORY, OR WREt(iN COUNTRY OF BIRTH 8a AGE-L�t BiRhday 8b. UNDER 1 YEAR Bc. UNDER 1 DAY & OATE OF BIRTH @Ao„ Dey, Yr.)
<br />(Y�a.) MOS. DAYS NOURS EAINB.
<br />f Grand Island, Nebraska 58 • March 99,1952
<br />y T. &OC1AL SECURI7Y NUAABQt Ba pLACE OF DEATH
<br />� 5Q6-72-8020 Hosarra� �x r�� �; ❑ N�ne Ha�ren.TC � HosPlce FaciQty
<br />�� Bb. FACILITY•NAME (U rrot 6mtihRlon, gWe street m�d numl�e) ❑ F.RfO�tpeverR ❑ Decaderrt's Home
<br />� Saint Francis Medlcal Center ❑ D ❑�rtga�rl
<br />c�
<br />=� Bc. CRY OR TOWN OR DEATH (Include Dp Godej Sd. COUN7Y OF DEATH
<br />,� Grand Island 68803 Hall
<br />Qa. RFSIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN .
<br />LL
<br />;;, Nebraska Hall Grand Island
<br />� a ,�d. 8TREET AND NUMBER 9e. APT. NO. 8L ZIP CQDE 9g. INSIDE CI7Y LIMITS
<br />$23 RBdwood Roed 68803 � Yes ❑ No
<br />� 10a. mARITAL 6TATU8 AT TIAAE OF DEATH
<br />� Mertied ❑ Never AAerded 10b. NApAE OF SPOUSE (Fltat, Middle, Lest, SuRix) flwNe, give maiden nert�.
<br />m i❑ eeerriea, b�n ee�cea p una�ea ❑ n�orcea p un�own Kathy Grabowski
<br />E 1�. Fa�rr��s-Naene !�. xaam�, ►.�+. s�c� �z anora��aw�eee ��r, evam�, esmaon s�e��
<br />v �/erlon Goosic � Maryorie Johnson
<br />� �3. EVER IN U.$. ARAAED FORCEB? (ilve datea M aervice HYea 74a MFORMANT-NAdAE 14b. RELATIONSHIP TO DECEDENT
<br />H
<br />�ree. No, m u�.1 No Kath Goosic Wife
<br />1& AAETHOD OF DISPOSITION 18e. EtlABALINER-SItiNATURE 186. LICEN$E NO. 18c..DATE (dlo„ Day, Yr.)
<br />0 �' � Not Embalmed Janua 2011
<br />�cremet�on ��nromm�re�e �Y 18
<br />; � ❑����� . 18d.CEAAETERY,CRE6lATORYOROTHERLOCATION CITYfTQWN 8TA7'E
<br />WesUawn Memorial Park Crematory Grand Island Nebraska
<br />77a FUNERAL HOMB NAME AND MAIUNO ADDRE88 (Streat, Ctty or Town, Stete) 176. ap Cale
<br />Livingston-Sondermann Funeral Home, 801 N. Webb Road, Grand Island, Nebraska 68803
<br />CAUSE OF DEATH (See instruetions and examples
<br />1& PART L Eroertha Wmtn olave� -�. Inluries� or eanp�eatlrns.thm �actry aaused the deeth. oo NOTemettmarhmt evema weh m em�ac enaet. ; APPROlOAlATE INTERVAL
<br />��� �P���Y er�e1. mvmUrleWarflbrNation rtthoiLL showing Me etlWopy. UO NOT ABBRBVIATE E�rter oNY a�e � on a�re. AEtl aE�Qdmrel Q�me U�me�sary.
<br />�rt �
<br />� IMMEDIATE CAUSE r ` � Slleet to deeth
<br />mdeaeowrE cause �Fl� �� 1 '� (�� � E �� / 7 /��
<br />me�ae ur eo�tdwon re�,�rir�g a� ��-�
<br />�n aeau,�
<br />�DUE TO, OR AS A CONSEQUENCH OF: ^ j� �� �/1 „� /� �orreet to death
<br />1/ � // d C/�� / n� re '
<br />Sequeneapy uat aondl6orre, 9 b) r V ,_�� l.�l
<br />a�ty� ta�g to Ure eause �d
<br />���� �' DU8 TO, OR A9 A CONSEQUENCE OF: � o� to death
<br />EMerfhe UNDERLYINO CAUSE �l
<br />(dleeaee or injury that Wtlated
<br />� e �� �� �� �) DUE TO, OR AS A CONSEQUENCE OF: ; o�reat to death
<br />LAST
<br />d)
<br />'i908. PAttT IL OTHER BIONIFlCANT CONDITION&COndlUmre aoMributl� b tlte death but rrot resutting fn tlre undeAying cauae glven In PART L 8. WAS NIEDICAL otAA�NER
<br />OR COROB�R CONTACTED?
<br />��l ►� ❑ YE9 NO
<br />�
<br />W ZO. IF ccMei F. 21e. AAANNER OF DEATH 27b. IF TRANSPORTAT[ON INJU a WAS AN AUTOPBY PERFORMEDT
<br />�❑ Na P�e wnnm a� rr� �� p r+�u�ra. ❑ nm�a�o�,ero. ❑ ves , No
<br />u ��� � ema m a�en ❑ awa�e ❑ P�aure tm�a�non ❑ Pesser�ge+ 21d. NIERE AUTOPSY FMDWfiS AVARABLE
<br />p N� w���, iwe Pr�e.,�, a: a� m a�m ❑ swwae ❑ CoWd not be detertM�red ❑ Paa�, TO COYPLETE CAUSE OF �EATH9
<br />� ❑ Not pregnaM,but pregnant 43 tlays to 1 y�r be(ore deetli ❑ or�. �ev�tr� ❑ rES ❑ No
<br />� ❑UnlmawnHpregnantwithlntlmP�l�
<br />� •
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<br />� 22a. DATE OF INJURY (Mo.� _DaY� Yr.) 22b. TIAAE OF INJURY 22c. PLACE OF MJURY-At hema. fenn, alrea6 taetory. olflea 6ulldi�, eo�retruction stt0. �(SP��fY)
<br />_ __ -- - _ _ _ _
<br />V -
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<br />� 22d INJURY AT WORK? 2'Le. DESCWBE HOW INJURY OCCURRED � �
<br />� ❑ YES ❑ NO
<br />YX. LOCATION OF WJURY • STREET S NUAABER, APT. N0. CIIY/TOWN STATE 9P CODE
<br />23a DATH OF DEATH (AAo, Day, Yr.� �� 24a DATE SIGNED (Mo„ Deyr, Yr.y TAb. T1AAE OF DEATH
<br />a� January 16, 2011 ' ,�� m
<br />� � 23b. DATE StQNED (Mo Day, Yr.) 2 ia TIeAE QF DEATH �> O Z4c, PRONOUNCED DEAD (eAo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />Z
<br />E�� � �� 2•17 am °'da''
<br />� � E � z0 m
<br />To tlre best of my Imowtedge, d tlme, dam end plece '� w� 24e. On tl�e bes�s of exeminatlon mullm InveeUgatlon, In my npinlon death axurted
<br />o mM due to the s) antl e) , � U at tlre Nme� dele m�d plaee m�tl due to the cauae(s) stated.191gnahue erM 71tle)
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<br />�18. DtD ?OBACCO U88 CONTRIBUTE TO THE DEATH? HAS OROAN OR Tl88UE DONATION BEEN CONSmERm? WRS CONSENT �RANTED�
<br />0 YES ❑ NO ❑ PROBABLY UN ❑ YES NO Not AppUeable B 28a Is NO ❑ YES 0
<br />Z7. NAAAE. AND 0� C (PHYSiC1AN. PHYSICIAW ABSISTANT. CORONER'8 PHYSICIAN OR COUNTY ATTORNEY) (TYPB m Print)
<br />� I 1 W�;�Q g,��.. ��v� � �Uz &fi' e�-- 980 .
<br />28a. RE SIGNATURE Z86. DATE FlLm BY REGISTRAR (Mo, Day. Yr.�
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