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ADAMS COUNTY REGISTER OF DEEDS:
ADAMS COUNTY, NE
FILED
INST. NO- 2~ O 7 2
Oats //-/~~~ Time ~%s"8 P,~
~~•
REGISTER OF DEEDS
November 16, 2007
Please file the attached death certificate of Larry Burdette McEwen against the
following described real estate:
Lot Nineteen (19), Block Four (4), Thompson's Addition to the
City of Hastings, Adams County, Nebraska, subject to easements
and restrictions of record.
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` ~. STATE'OF'NEB6ASKA;; 0~,1 .5( ~42 - ,
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' "- WHEN.THIS CORY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES.. ' , ~ ; '
;, SVSTEM,~IT CERTIFIES THE BELOW TO BE A TRUE COPY OF~THE ORIGINAL RECORD~ON FILE:WITH'~ ' - ' ' '
THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTlCS'SECTION_.WHICH'JS _°.
THE LEGAL DEPOSITORY FOR VITAL RECORDS. - ~j~/~J-
' ~ ~. DATE OF ISSUANCE - ~ ~ ~ ~ ~ ~ ' / ~ ~~" 71 ~ r ~ ) ~ ~-
MAY' 1. ~ ZOOS - l`~~Q~~TANLEYS'„C-OLORER_ry j ,'
ASSf$TANT,~~iAT,)= Fi~6/ST~iAR _': ,
. _: LINCOLN, NEBRASKA ~ ' '
' HE ~ N yqy ,SERVICES .,,
i ra4 / i:Il Y 7Tj~4~1T~.:1 s ~' s h
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' ~ ~ ~ ~ STATE OF NEBRASKA_DEPARTMENT OF HEALTH~ANDHUMAN SERVICES FINANgE,4NB SUP ~ +
- ~ i CERTIFICATEOFDEATH `- ___m.~~~,~.~~51~69,.
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.1. DECEDENT'S-NAME. (First Mitltlle, Lasl, ,..~ 'Suffix) % 21'$EX Y6 3 OATE'OF DEATH (MO:,'Dey Yr.) '
Lair Burdette McEwen Male '~ Ma a~4,~'2-0-07
. 4 ~ ' 4.LITY AND STATE OR TERRITORY; OR FOREIGN COUNTRY OF BIRTH fia. AGE-Lest Birthtlay 6b. UNDER 1 YEAR ~ 6c: UNDER i DAY-'' sBrDATE OF. BIRTH (MO., Dey, Vr.)
• . ~ (Yrs.)_ ~ MOS: GAYS ~-. HOURS ~ MINS.~ '/
`
•.' ' `'Cla Center Nebraska
- ~ " 72
-
' ~
August 4, 1934
7. SOCIAL SECURITY NUMBER ~
506-32-0595 6a.PLACE OF DEATH '- - ' -
r
~
'. ~ ~ HOSPITAL: $( Inpatient
Qp¢g ^ Nursing HomelLTC Hospice Facillly
~ ; ~eb. FACILITY NAME (11 not Inslitutlon -glue stree6and"nu mbe0'
~ - ;' ^ ER/Oulpellent ^ Decedent's Home
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. ;
I . ~ .. . ..., ... r ~ ., .. .... .... .. .. 1
...
s
D ~ 'Mary Lannng Memorial Hospital
, ^ w, ^omar~spppuy)
° Bc. CITY OR TOWN OF DEATH Uliclude Zlp Code)
"
Bd. COUNTY OF DEATH
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_ Hastings 68901
~ Adams
• 9a. RESIDENCE-STATE
. 9b.000NN 9c. CITY OR TOWN '
~
~t Nebraska ~ • Adams Hastings
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~
5~~, ;,9d. STREET ANDNUMBER - 9e. APT. NO 9f. ZIP CODE 9g.INSIDE CITY LIMITS'
y
~ 603 E:. "5th Street' b$901 ~ Yes o No
1 Da. MARITAL STATUS A7 TIME OF DEATH $) Married U Nevei Mewled 10b, NAME OF SPOUSE IFirsl, Mitltlle, Lesl, Sulflx) If wile, glue maiden name.
.
- .
~ .
. ..
`'OMarrled,bulseperaletl'~Witlowetl ^Dlvorced OUnknown
.~
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( +~}" ~ Charlotte Alloway
11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME . (First, ~ Middle, Malden Surname)
~'~'~ Gerald E. McEwen Marie L. Pennington
13. EVER IN U.S. ARMED FORCES? G}~,g¢pesolsarvice if yes. 14a.INFORMANT-NAME - 14b. RELATIONSHIP TO DECEDENT
) . (Ye~y{p, r~nk28, 1951-Nov. 7, 1952 Mrs. eila Thom son Daughter
` 15: METHOD OF DISPOSITION 6a.EMBALMER-SI T RE 16b. LICENSE NO. ~ tfic. DATE (MO., Day, Yr.)
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' ~BUdal ^Donallon , 951 Ma 8, 2007
r,: ^Cremallon ~Enlombment 1 .CEMETERY, CREMATORY OR OTHER LOCA ON--' CITY/TOWN STATE
^Removal ^Olher(Specily) 6tOCkholm Swedish t
Church Cemetery Shickley, Nebraska
17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clly orTown, Stale). _ 17b. Zip Code
`~~,„I 'McLaughlin Funeral Home, 113 N. Brown Av, Clay Center, NE 68933
'yl„ ~I~ IuYt ~ t d6'" iC'„US OF~~DE'AT}r1~~See ~''st~GcSions~aod~{exiii~"'le`s),,#~. ,~1~n,~ RS,~~ "
18. PARTLEnter lhp nha'n of avenls~-tllseases,in)urles, or complicetlons--Ihal~diraclly caused the tlealh. DO NOT enter terminal evenly such es cartliec arrest, APPROXIMATE INTERVAL
I
respiratory arrest, or ventricular librlllallon wllhout showing the ellology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add atltllllonal lines II necessary. I
- ~ IMMEDIATE CAUSE: ~ I onset to death
~
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N' ~ ~ - I
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' (a) I~£~ ~~'
IMMEDIATE
_
CAUSE (Final
~~ tliseasa orwndidon resulting DUE TO, OR ASACONSEOUENCE OF:
In tlealh) ~ I onset to tlealh
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Sequentlally llsl conditions, it ro)"
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gyy
` any, 1¢atlingtotha caux liatetl DUE TO, OR AS ACONSEOUENCE OF: I
online e. ~ I onset to tlealh
f EnMrthe UNDERLYING CAUSE I
(disease or in)urythel lnlUalpd (c) I
p- the events resultin
in death)'
g
DUE TO, OR ASACONSEOUENCE OF: '
lAST - I onset to tlealh
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l 18. PART IL OTHERSIGNIFICANT CONDITIONS-COndillonscontrlbuling lolhetlealh butnol resulting In the underlying cause given In PART I. 19. WASMEOICALEXAMINER
.. ~,'~]~ ~ ~~",~ . ~~' ~,~ ~ OR CORONER CONTACTED?
A.
~ ~ ~ ~ ^ VES ^ NO
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~ 20..1E FEMALE:. ~ 21 e.
M
ANNER OF DEATH 216.IFTRANSPORTATIONINJURV 21 c. WAS AN AUTOPSY PERFORMED?
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~
~ Nol pregnant wllhin past year y(Natural I]HOmlclda ^Odver/Operator
j ~~ ^Passen ~ YES I~yNO
I O Pregnant et limp of dealfr - ^ Accitlenl~ Pentling Invesligptlon gar ~ "'1
~ ~ O Nol pregnant, but pregnant wllhin 42 days of tlealh ^ Pedestrian
~
~ pfd. WERE AUTOPSY FINDINGS AVAILABLE TO
^Sulcitle OCould not be delerminpd
f~; <]Olher (Specify) '
~ ~N0l pregnenl, but pregnant 43 days lolye~r belare tlealh -
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~
~ COMPLETE CA
SEOF DEATH?
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y Unknown ll pregnenl wllhin the Dast year ^ YES ~?JO
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22a, GATE OF INJURY (MO., Dey, Vr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-ql home, term, slrei!I; lectary, ollice bullding, conslruclian site, etc. (Speclly)
_ _. _-_. _ ._ _ _ -___ _
_ ___._________,___..__-_-.. __-..___.-. _____.-__-_.-_
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22d.INJURV AT WORK? 22e. DESCRIBE HOWINJURV OCCURRED _
~ B ^ YES ^ NO
221.LOCATION OFINJURV -STREETS NUMBER, APL NO. CITY/TOWN STATE
ZIP CODE
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~
ii~~ 23a. DATE OF DEATH•(Mo., Day, Yr.) 2d
DAT
e.
E SIGNED Mo., Da Yr. 24b.TIME OF DEATH
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7 ~S aia 23b. DATE SIGNED (Mo., Day Yr.) 23c.TIME OF DEATHy d~ik 24c. PRONOUNCED DEAD.(MO., Day, Yr.) 24d. TIMEPRONOUNCED DEAD
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( 5q u ~ 23d. To the best y knowle ge, ea occurretl al the Ilme, dale antl lace ~
n~ p dw 24e.On lhebasisof examinalion antl/orinvesligallon, In myopiniontlealhoccurretl et
antl due 1 causelsks led. i el re nd Title)
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me, data and place end due to Iha teasels) staled. (Signature antl Title)
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" 2fi. 010 TOBACCOUS CONTRIBUTE TOTHE OEATHt 26e. HAS ORGAN OR TISSUE DONATION BEEN CONSIOERED7 :26b. WAS CONSENT.GRANTED7
d k i ^ YES ^ NO QPRDBABLY ~ UNKNOWN Q VES $1 NO Nol Applicable II 26a is NO OYES 61 NO
r'-v Z7.NAME,TITLEANDADORESSOFCERTIFIER (PHYSICIAN,CORONER'S PHY _ d_IJR,~'$i'T Q arc .
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,,m Dr. David R. Little, M.D'., 21T5 N Kansas Av, Hastings, NE 68901
28e. REGISTRAR'S SIGNATURE 26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
~, MAY.1 0 2007
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