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099 NEBRASKA
DOCUMENTARY STAMP
TAX
Da~t9LL: ~ b • n 7 By.~
~ 83. as
Exem #
IIIIVIIIIIIR~VIII!III~
NUM ~ ~
RD. COMP x ~ ~-oo~
COMPARE ~~~
CADAS `I-/d- ~ AO /
oK,tkt
WARRANTY DEED
ADAMS COUNTY, NE
FILED
INST. N0._,~~Q.~.sS O `~ 1
Date 11-1!x_ T~m~., 3 s~ ~m
REGISTER OF DEEDS
William R. Mitchell, a single person, Grantor, whether one or more, in consideration of One Dollar and other
valuable consideration, receipt of which is hereby acknowledged, conveys to Daniel J. Schwartzkopf, Trustee
of the Daniel J. Schwartzkopf Revocable Trust, Grantee, the following described real estate (as defined in
Neb. Rev. Stat. § 76-201) in Adams County, Nebraska:
Lots One (1); Two (2), Three (3), and Four (4), in Block Three (3), in Taggart Addition to the City of Hastings,
Adams County, Nebraska, according to the recorded plat thereof.
Grantor covenants (jointly and severally, if more than one) with the Grantees that Grantor:
(1) is lawfully seized of such real estate and that it is free from encumbrances subject to easements,
reservations, covenants and restrictions of record.
(2) has legal power and lawful authority to convey the same;
(3) warrants and will defend the title to the real estate against the lawful claims of all persons.
Executed: /(' `lo'
William R. Mitchell
STATE OF NEBRASKA )
,.-~ ) ss.
COUNTY OF!~j~~2~1~~% )
The foregoing instrument was acknowledged before me on ;~~ ~ j' jd , 2007
by William R. Mitchell, a single person.
(SEAL)
My Commission Expires: / ~2 - o i ~ J y___~_..
~, 6H'~#~P.401AAY~t811 of NRbras'~a f~
JOYGEaCHIACfiTER ~j
67y fomm. Fxp, J,a.;.I _~ fJ
2007.
Not ry blic
ofd
_ , -':: STATE OF•,N.EBRASKA ~. .:°' 2 O 0~"1x5 O,'71~ -
`' '• `WHEN THIS.COPY CARRIES THE RAISED SEAL'OFTHE NEBRASKA HEALTH AND.'HUMAN SERVICES:
( -" SYSTEM, IT CERTIF/ESTHE BELOW:TO!BEA~TRUE COPYOFTHE ORIGINAL RECORD ON•FILE WITH •- . - _'
' ' ` -' ' THE NEBRASKA HEALTH AND HUMAN SERVICES.SYSTENI,: VITAL STATISTICS'SECTION ?WHICH IS,
- THE LEGAL DEPOSITORY FOR VITAL RECORDS. • `' 1`n.r+' s "'~ "
.. .... DATE OF l¢SUANCE ~t~ "°'0 ,L~+a.( I~ I -
_ 1 ~ ... - ~ srr' s++j tf tl fr•..1) ylsih,dtl'. , ..
. ; ,,, ~ :}} jANLEYS,t,COOPER ~ ~ "
- LINCOLN NE~ASKA .. ASSISTf1N,T SfiATE REGISTRAR{ ,`' r' . ~ __
HEALTH AND HUMAN. SERVICES j + }
STATE'OF NEBRASKA-,DEPARTMENT OF HEALTH~AND HUMAN SERVICES FINANCES S P ORT ~ ~ ")f~?:u "'a ;'~
' CERTIFICATE OF DEATH '' 1 ly " ~ - ' '
' "• ~4 ~~ 27'5`82'
~:
'~':~
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•f DEC
l r
' ~ ,
EDENTS-NAME (First,.. - Mitldle,, 'Last, a -~ ,.
~ - Su111x
t
''
~
SEX
+
3 DATE OF DEATH Mo Da Yr -
~
Shirley A Mitchell . ' '
- ' '
~ - -
pegt~le / .?i ,July 10''2b07 ` ' irl',; "
' '4 gITY AND STATE OR TERRITORY; OR FOREIGN COUNTRY OF BIRTH
" Sa
AGE Le
t Bl
~
3
v
.
.
a
rthtlay
6b.UNDER (YEAR 'SCrUNDER
I DAY;'.; 6~DATE OFnBIRTH (Mo `Day Vr)~
-
-
p ,1 •
.. (Yrs.l :MOS. DAYS HOURS rMtNS {~gtY,l"'a71 '17 rt ra;~ _.,
~•
H
sti
i
-
Y
~
~
~
~
.. .
a
a
ngs; Nebraska
-' ;
' " a) . e'
i '' iT 1ti~~
69 - - ~
- .
r ,. December26.193T~
~. '7. SOCIAL SECURITY NUMBER - ~ -
' + -° ~
~ - ~ .
~ 6a. PLACE OF DEATH • -- - _
506.42-4969 "- '
'.
o HOSP T~ r:^
A : InpeUenl ~ O1HFA. ^:NUrsing Ho /LTC ^Hosplce Fatllily
f Bb FACILITY,-NAME (11 not Instil ution give street and number) - r l -. _ mo
..
FF--
o 1
,
- -
(~ .. .... .. ,. ,^ER/OU~atlent ~. 'Decetlenla Home
-'
is r ,
415 Ringland Road
~
o
.
... U or,
^ olner(speary)_
'
,~ Bc CITY ORTOWN OF DEATH(Inclutle 7Jp Code), - '~
W ' ~ ! 6d.000NTY OF DEATH
Hastings' 68901
~ -
.
' .¢
~ Adams
{ Pa.RESIDENCE.STATE -
~
Bb
000NTY
-
'
;
y . _ ,., .-, ,,,
.
.
&.Cn
YOR70WN
"~ ~ Nebraska Adams Hastin s' - - -'
,m g Pd. STREETAND NUMBER; -
;~• -' Pa. APT:-NO 91. ZIP CODE Pg.INSIDE CITY LIMITS'
. 415 Ringland Road , ~ - ~ ~
~
-, m'; 68901
' ~ YES ' U' NO
fOa. MARITAL STATUS AT TIME OF DEATH ~Marrietl~UNever Marned tOb. NAME OF SPOUSE
FI
l
Ml
' ~ ~
-a. (
rs
,
dtlle, Lasl, SUtllx)Il wile; glue maltlen name.
i .. ..
-
!E ~ ^Marned, but sepamled ^ Widowed U Divorced U U
k
~
- '
3. n
nown
~ -
- William Mitchell
' mm, 11. FATHER'S-NAME (Firs 1, -~ ~ Mldtlle, Last, Sullix)
' " ~ '
" 12. MOTHER'S-NAME (FIrsL ~~ Mltltlle
-~-~
ed
•
Victor J LaPorte '
' , ' '
- ,
- -
- Surname)
.. - , . • Mold
Adella Komrotske ' '
13. EVER IN U.S.ARMED FORCES? Give dales olservlce ilyes. 14a.INFORMANT-NAME
' ~ ~ _ 14b. RELATIONSHIP i0'DECEDENT '
(vea, no, Drunk.) No - ' William Mitchell -
~
i6, METHODOFDISPOSITION ~ I6a.E
MER-SIGNATURE ~ - HUSband
I6b. LICENSE NO.' - '~ I6c. DATE (MO., Day. Yr.) -
® Budal ^ Donation ' ry -~
1
-
, /
July 13, 2007
^Cmmatlon UEntoinbment 16 .CEME RY,CREMATO ROTHER LOCATION
'-
-
CITY/TOWN
STATE
~
U Removal ^ Other (SpecrtYl
~~ ~ ~. ~ ~ -
1
.
'.. ParkviewCemetery ~
~
Hastings
~ Nebraska
17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty mTOwn, Stale)
Brand-Wilson Fu
l H
nera
ome, 505 N Bellevue, Hastings, Nebraska tTb. zip code
68907
' - ~ " -CAUSE OF DEATH (See instructions and examples)
ie.IpART LEnler the chain of events:-Ulseases,Injudes, orwmplicallons--ihal dlredly causetl the tleaN. DO NOT enter terminal events such as cardlec anesl,' 'APPRO%IMATE INTERVAL
'
i
~
.
resp
ratory anes6 orvenirlcular libnllagon without showing the etlology. DO NO7 ABBREVIATE. Enteronly one cause on allne
Atltl additl
• .
onal linen ll necessary.
i
~ ~
~ - ~ ~ ' ~ 1
.IMMEDIATE CAUSE:
~ ~ ~
onset to tleam
-
i
IMMEDIATE CAUSE(Fhal la)
~Ir~ ~~
~
~
I
' tlkeese acontlgb
'
"
--
nrewlll
,
I
rq 'DUE 70,0 ASACON OUENCE OF:
,
~ ,-
hdeelh)
-
--
V
.
.
I onset to dealh~
~
-
_.Sequenllalty lklcontllllans, if lb)" ~ ;, ~ ~ ~:~ - ' - I '
VV
I
eny, leading to the ceuw tlsled
' I
DUE TO.OR ASA CONSEOUENCEOF'
on line e. ~ ~ ~ ~'
• . I onael to death..
~~Enltt OIe UNDERLYING CAUSE. - ~ - '
I
~ ~
.
(dlaeese arlnlury Nat lnlllatea (c) ~.~ ~
~
' I
'
tlle avenkresullinghtlaeh)'~
DUE TO.ORASACONSEOUENCE OF:
(ASf
•
~ ~
-
- ..
_, ~ I ousel to deaN
~
~
..
.
- .
..
.. .... I
I6. PART IL OTHER SIGNIFICANT CONDITIONS~COndlllons conttlbufing la the death but not resulting In lha underlying cause grvemn PARTI. 1B. WAS MEDICAL E%AMINER
. -. ~:.-~ _ ", ~ ~ - .. _ ' Ofl CORONER~CONT/AC,TED'x '-
,
~U
..,..
W
ly _
YES I~YFO
20. IF EMALE : ~ :21a. MANNE FDEATH
- - ~ 21 b. IF TRANSPORTATIONINJURY 21 c. WAS AN AUTOPSY PERFORMED?
~' Not~
re
n
l
i
h
~
^
- ~" '
F . p
g
an
w
l
ln paslyear
-- - ural
HOmldtle
UDtlveuOperalor
U
U YES b"'•"'
: ^ Pregnant atUme of Uealh~ ^Passenger
^ AcdtlenlU PenDInU Investlgallon
~. U Nol pregnant but pregnantwllhlh 42 days of death; ~. ~ - ~^Pedeslnan
m • ~~ 175udtle ^Cauld not be detemllnetl 21tl. WEREAUTOPSV FINDINGS AVAILiBLE TO
^ Not Dregnanl, but Dreghant 43 days totyear Delore deaUl °'' ~ ~ ~ ^Oher (Spedly)
ar
3. ~ ~ • ~ COMPLETE CAUSE OF DEATHI
^Unkndwnilpregnanlwithin thepaslyear -~ ~
o ^YES~ UNO
-
p ~ .22a: DATE OFINJURY'(Mo., Day, Yr.)--.` 22D. TIME OFINJURY ~ 22c. PLACE OFINJURY-Alhome; term, alreel; laclory; olllce grlltling;conelructlonslte,elc.(SpedtyJ-
m
~
'
. '[2QINJl/R1'AT WORK?, 22e. DESCRIBE hIOW INJURY OCCURRED --' ,
•
.
. U. YES ^ NO -
' 221.LOCATION OFINJURY-STREETS NUMBER, APT NO. CITY/TOWN ~ ~ '
-
.
STATE ZIP CODE
'
~ 23a. DATE OF DEATH (MO„Day Yr.) ~
'~~
Jul
10
2 za '.. 24a. DATE SIGNED (MO., Day: YU) ~
'
` 24b. TIMEOF DEATH
.
y X
,
007 a
oZ m
$y 23b
DATE SIGNE .
Q
.
D (Mo., y,Yr, __ 23c. T1ME OF DEATH
J
'
~' '
E ni< 2dc.PRONOUNCED DEAD Rdo., Day,Yr.) 24tl.TIMEPRONOUNCEDDEAD
5:12
a m
do.
$ E~y~ m'
a 23tl. To the best of rtry kn ledge, death occurtad at the time, date and plats
n y and due to the tau e(s)slaled. (SlgnaWre and Tille)• ~ w z0
24e. On lne basis of examinatlonaM/m lnvesUgalion, In my aplnlon death eccunatl at
mz~
~ ¢ ~ ~ n
~ ~ the Dme, dale antl place antl due to me cause(s) slated.l9gnalwe antl 71t1e) • .
F
25.
D~IDTO~R4000 USE CONTRIBUTE TO THED H? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'+ 26b.WA5 CONSENT GRANTEDv
,
u+'Yt5 ^ NO ^ PROBABLY -^ UNKNOWN - ~ ES ^ NO ~
~
_ ~
Nol AppllcablaN26a 1s N0 L1- YES
27. NAME, TITLE AND ADDRESS OF CERTIFI ER (PHYSICIAN
CORONER'S PHYSICIAN On COU
,
NTY ATTORNEYI (Type or Pnnl)
' % Paul C. Wibb.~els, MD; '2.1.15 N. Kansas, Hastings, NE 68901
26a. REGISTRAR'S SIGNATURE'
~ 2BD. DATE FILED BY REGISTRAR (MO,. Day, Yr.j
i ; .. _ : ,...-
' iJUL 16 2007 ..