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ADAMS COUNTY, NE
zoo~sis~ INST. N0. f_ ~0 f ~ i $~
NUM ~5.-~ `"Tr~s~t~~~%o(cl Oate I,- ~-o~ Time =13 /~M
RD. COMP X ~ 'S`~o?/ ~' $~'~
COMPARE REGISTER OF DEEDS
CADAS _ AO '~
g. s g` ,I~6/9/2i0N03~1 ~~~% ~ ~ do s; :N( a",:
° ' ~ LlNCOLNT NEBRASKA' a ! ''' ; ~ • ~ y"
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~ 2 c ' ` ~ 7 ~ Ad ~ " STATE OF NEBRASKA DEPARTtr¢NT
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c~ uc~tutnl rvAMt (' FIR$T~ 4 r Y MFIDDLEv d j .. LAST S ~N"! F 2ySEX jta 3 DATE OF,DEATH !Month. Oay Year) [5 ~ p „,
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• 3~ 1?- la Leonard r ~~ 'E '- ~~ Crick' ='- it dMale '. June 2
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14rv CITY AND STATE OF BIRTH q/Il notm USA ame country! 2 t } 6aY AGE Laapl B tlhtlay 'UNDER 1 YEAR '' UNDER 1 DAY 6 DATE OF BIRTH lMipnM Day Year/
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DAYS y6YHOURS {MINS
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HOSPITAL Tln afanl ;OTHER 1 ~ - 1 4 g 9
1 I .' 0 P -Nursing Home r
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Bb FACIUTY'Name 1"e /l/r•ofi sliNhon give street and umber/ ~ ( ~ s - {~ ER Outpallenl Res de ce
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l.'B1ue:Hi11:'Care Center ;~°' ~~~' ~ `~ ~ '"
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.. Bc ;CITY TOWN OR LOCATION OF DEATH ~ " .. -~
, r ,. fitl..INSIOE CITY LIMITS.. 6e. COUNTY OF DEATH
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9a RESIDENCE`-STATE ( "1 k 9b COUNTY ~ 9c, GITY.JOWN OR LOCATION - ',' 9d. STREET AND NUMBER' /Including Lp Cpdel ' 9e INSIDE CITY LIMITS'
;Nebraska '':' -Adams Hasten s.: ~
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233 N.:Hasti~ s`68901 -ve:• -Nn
90 RACE-Ie.g.. White BIacN American lndmn, : '
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~ , . 11. ANCESTRY leg Malian. Mexican German, elcl
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., 13. NAME OF SPOUSE ~~III wrvle give maiden name) '
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•~ -White'
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MARK, '
14a. USUAL OCCUPATION /Give kmda/work done during most ' 14b.'. KIND OF BUSINESS INDUSTRY, ' ' ' ~, ~ ' 15. EDUCATION Specity only highest grade completed! -
o/working lets, even i/reliredl --- ~
~ ~ 'Elementaryor Secontlary 10-121 College 11-4 or69' ,
12
16. FATHER-NAME - FIRST MIDDLE. LAST n. MOTNER - FIRST
MIDDLE ' MAIDEN SURNAME
..
'Ha'rry
Crick Louise
Becker
16. WAS DECEASED EVER IN ll.S. ARMED FORCES? /,-23-194 p 19a. INFORMANT-NAME
Y
G
(Yes. no. or unk.l 111 yes, give war and dales of servlcesl
~
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Yes WWII" 7-10-1944 P~tF_rE,;a;:Aeddick
mu. uvnvmm~rv i Mnlurvti AuuHt55- ISTREET OR R.F.O. NO-CITY OR TOWN. STATE. ZIP( - _ .
624 N. '4th Ave.', HastinQS, Nebraska 6R9(11
( 1 I..
n II,.
`° "^°"" 21 a. METHOD OF DISPOSITION 21 b. DATE 21 c. CEMETERY OR CREMATORY ~ NgME '
I ~ /~ ~ LpJ
Y` "di' .' ®BuriaL ~ Renwval. Jllne 5 2 ~ ~. 1 .
22a. FUNERAL HOME-NAM -, ~ ~ ~ ~ 21d. CEMETERY OR CREMATORY LOCATION:. ~ CITY OR TOWN ~ STATE ,
Livingston-Butler=Volland F.H. Ocrema6°^ Qoonall°^'
22b. FUNERALHOME ADDRESS ., ISTREET OR R.F.O. NO.: CITY OR TOWN. STATE, ZIPI _ - ,
1225, N. Elm'.Ave., Hastings, Nebraska 68901
23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR IaL Ibl. AND Icll ~ I Interval between onset and deala
PART - ~. 1
I e - - ~ ~ I
lal ~~/L1 a~ L~ ~lAit ~ - I ..
DUE TO, OR AS A CONSEO NCE OF .- I Interval between onset and tlealh
... i7 -. .. /' .. ~ I..
I°I l_..A1'u.0'r•L<I '~ yr.U~ oval ru z.
' ~d ^'DUE:TO:Oq A3ACONSEOU OE CF ^~~ »
~ . Id. ..-.... - .,
l
i.
I
i onset and tlealh . '
UIMER SIGNIFICANT CONDITIONS -Conditions cpntribugng to the tlealh but not related
PART PgRT III IF FEMALE. WAS THERE A 24 AUTOPSY ' - 26. WAS CASE REFERRED TO MEDICAL
°
II PREGNANCY IN THE PAST 3 MONTH57 EXAMINER OR CORONER?
_
q~~~~ _
- vl .+!/IVI ~ -
(Ages 10-541 Ves No
Yes NO Ves No
26a. -' 26b. O E OF INJURY' /MO.ADay. Yr/ ' 26c. HOUR OF JURY 26tl. DESCRIBE HOW INJJRY OCCURRED
Accident 'Undetermined ~ ~ ~ .
M
Suicitle, ~ Pending : 26e. INJURY AT WORN q EE
A~y%'tarm. street. ladory
261. office bwlding.IeIRV
S 26g. LOCATION STREET OR R.F.D. NO. CITY ORTOWN STATE
Homicide ~ Invesligafion
Ves ~ No ~ / .
2]a. DATE OF DEATH /Mo.. Day. nJ 28a. DATE SIGNED /Mo.. Oay Yrl 266. TIME OF DEATH
~~ June 2,.2003
a 'T<~
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2]b. DATE SIGNED( /Mo.. Uay. YrJ 2]c TIME OF DEATH
_ir
~ g o ... M
~ i a J 26c. PRONOUNCED DEAD IMO. Day, Vrl 26tl. PRONOUNCED DEAD /Howl
a g 3:25 A M ~' w ~ o
'M
:. >a 2]d. To the best o1 my knowletlge. tlealh pccurretl al the lime, dale and place and due to the ° °¢ ~ 26e. On the basis of examination antl~or investigation, in my opinion death occurretl at
~
causelsl staled °~ o , the lime, dale and place antl tlue to the causelsl staled.
// // ~~
ISi nature and Tillel - ' ic(,('/ ~ ~'UL>/ll'v. ~Q/~ ISi nature antl Title - •
29. DID TOBACCO USE CONTRISUTET THE pEATH7 ~ 30.a HAS ORGAN OR TISSUE DONATION OEEN CONSIDERED? 30.b WAS CONSENLGRANTED4
VES ® N0~ ~ UNKNOWN ~ YES ~ NO ~
~
VES
NO
3L: NAME AND ADDRESS OF CERTIFIER(PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY( !Type aPring ~ ~ - ~ ,
I ..
'Michael G
Sk
h 'MD
2
'
.
oc
.
2
E s 1
32a: REGISTRAR ~ _. ~ 32d qTE FILED RV REGISTRAR /MO. Day. Yc/ ~ ~ -
JUN ~ " 6 2003
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