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DOCUMENTARY STAMP
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NUM 11/~
RD. COMP
COMPARE
CADAS ?'
AAAMSCOVf~T`(,iVE o;<up„
FILED
INST. N0._2~rJ 3 ~, 8
Date ~2 -S-o7 Tilde /.?: z T /°..N,
REGISTER OF DEEDS
PERSONAL REPRESENTATIVE'S DEED
GREG A. POWELL, PERSONAL REPRESENTATIVE OF THE ESTATE OF RALPH A. POWELL,
DECEASED, Grantor, in consideration of One Dollar ($1.00) and other valuable consideration, conveys
to KELLEY A. SHAFER AND NATHANIEL M. SHAFER, Grantec,_as joint tenants and not as tenants
in common, the following described real estate (as defined in Neb. Rev. Stat. § 76-201) in Adams County,
Nebraska:
Lot Fifteen (15), Block One (1), in Model Homes subdivision the City of Hastings, Adams County,
Nebraska, according to the recorded plat thereof.
Grantor covenants with Grantee that Grantor has legal power and lawful authority to convey the same.
Executed: ~~ - ~~~ '"-
Greg A. ell, Personal Representative
of the Estate of Ralph A. Powell, Deceased
STATE OF~~,+~E~_.`{U: ~..~ )
/-/ ) ss.
COUNTY OFG•,c"G~Z- ~~-e/
2007.
The foregoing instrument was acknowledged before me on /f ~i~,~t~rz,~,.~-/ ~ (', , 2007
by GREG A. POWELL, PERSONAL REPRESENTATIVE OF THE ESTATE OF RALPH A.
POWELL, DECEASED.
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DFotar;~ Public
(SEAL)
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:: ..STATE OF NEBRASKA. ~ Q Q ~ 5 3 ~ 8
' .WHEN.TH/S CORY CARRIESTHE RAISED SEAL OF THE NEBRASKA HEALTHANO HUMAN,SERVICES
` SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL REGORD O_N_F(LE•WITH
.. .
THE NEBRASKA' HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS-`SECTION iNH/CH lS
THEILEGAL.DEPOS/TORY FOR VITAL RECORDS..: >. ~ `° ~
f . ~ _ .. i tp~~ JS
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• DATE OF ISSUANCE' ~ r 2 K~/,_
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I . ~ 'lot-) ~ TA7VCEY~ CD~PER
, "a ~t~~ASSISTYINT_`STAT~RE~ISfiI~AR-
LINCOLN, NEBRASKA ` HEA€IH"ANCtH(~MAN''S HV(CES
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' STATE~OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOp,T^ n
~' ~ CFRTIFICGTF C1F IIFATH' ' + :++../)i.,l.~u '1-1-~i ~ 'S~Q'Q f 1
r,(,~-~ 1. DECEDENT'S-NAME (First, ~ ,Middle, Lest, ~ - ~; SUlllx) 2.:SEX., ~""I'' ''3. DATEOFDEATH (MO., Oey,Yc)~
r Alice .Tune Powell Female December 1, 2006
~" 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 5b. UNDER 1 YEAR 5d. UNDER 1 DAY 6. DATE OF BIRTH (MO., Day, Vr.)
~~
• rairiield, Nebraska (Yrs.)' ~
88 MOS. DAYS HOURS MINS. ~`
June 26, ]:918
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W~,~ : 7.SOCIALSECURITYNUMBER ~ ,Ba.PLACEOFDEATH
;
~oh09~fi0I>_ HOSPITAL: ^Inpallem ~ ONUrsing Home/LTC ^HOSplce Feclllly
3G: FACICIT'+11M E' (ILnol Insfi!u!ibm,.glvs sVeeL and number)-.__- -_ ___. _ __. _.-. ,"___- _
-'^ ERIOUIpellerl~--~---Ct~Aecedanl's Home
1107 West .12th Street
._ .: _ ~ - .. ~ ^ N1 ~ ~ ^ Olner (SPecilY)
~ Bc: CITY ORTOWN OF DEATFI (Include Zlp Code) Bd. COUNTY OF DEATH -
t~
Adams '
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Ebb, 9a.RESD NCE
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' 9b.000N11' 9a CITY OR TOWN
~' Nebraska' Adams Hastin s
9d. STREETAND NUMBER ~ 9e. APT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
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~~ 1107. WP..St 12th Street 68901 ,~1 YES ^ NO
10e. MARITAL STATUS AT TIME OF DEATH $1 Married ^ Never Married tOb. NAME OF SPOUSE (Flrsl, Middle, Lasl, Sullix) II wile, give maiden name.
~a ^Merrled, hul separated ^Widowed ^Oroorced ^unknown ~ Ralph A. POWell
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11. FATHER'S-NAME. (Flrsl, ~ Middle, Lasl, Sullix) 12. MOTHER'S-NAME (First, Mldtlle, Meltlen Surname)
Fxank Wheelex Henrin_tta Bryant,
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13. EVER IN U.S. ARMED FORCES?Give dales of service llyes.
(Yes, no, or unk.) NO
14a.INFORMANLNAME
Greg POWP_11 ~
14b. RELATIONSHIP TO DECEDENT
SOn
~
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~~>i' 15. METHOD OFDISPOSITION 16e.EMBA ERSIG URE / 1fib. LICENSE NO. 16c. DATE (Mo., Day,Yr.)
~BUrI¢I ^DOnallon ~~_A ~~7 DP_Cem17 P_r 7, 2006
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~`ri6.v 16d. CEMETERY, CREMA ORY OR OTH LOCATION CITY/TOWN STATE
^ Cremetlon ^ Entombment
^ Removal ^ Othar (Speclly)
Grand Island Cemetery .Grand IsJ.and Nebraska
t7a. FUNERAL HOME NAME AND MAILING ADDRESS (Sireel, Clly orTOwn, Blale) 1225 North Elm AV enlle 17b. Zlp Coda
'Livingston-Butler.-VolJ.and Funeral Home Hastings,~Nebraska 68901
.A;& , ~~--~'i~~s€~~:~-~ v.* ,.a`I..~~'le*' .~a~YE"»~,..,G'A'U„fiS. FiO~,r"~by8i+~1 ;F(,S:¢~ IJi§tE~E{~.`~ TI"?"~~if les,gr'... >•,.r. ~i~'~"~i ~ ,,,~
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, 1B. PARTLEnler the chain al events--diseases, Inlurles, or complicellans--Thal directly caused the death. DO NOT enter terminal events such as cartllec arrest, APPRO%IMATE INTERVAL
I
S resplralory arrest, or ventricular llbrlllallon wllhoul showing the etiology DO NOT ABBREVIATE. Enter only one cause aneline. Add eddlllonel lines ll necessary. I
~~~
,~, )
~~ ~ IMMEDIATE CAUSE: I onset la death
,. I
IMMEDIATECAUSE (Final la1 Cardiac arrest ~ Immediate
~f,l l),
' tllseaseorcondllion resulling DUE TO, OR ASACONSEOUENCE OF: I Ansel to death
.
Indealh) I
^13c
~': Sequenllally list condlllons, if ro) l
_~ongestive l~~t ai e I
I anV, leading to the cause listed DUE TO, OR AS ACONSEOUENCE OF: I onset to death
on line a. ~ t
~~
~;'')k Enlerthe UNDERLYING CAUSE I
(diseeae orln)urythet l¢Itlaled~ (c).
'
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' . Iheevenlsresullinglnd¢alh) DUE TO, OR ASACONSEOUENCE OF: I onset to death '
LAST I
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(~
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?g; ', 18. PART ILOTHER SIGNIFICANT CONDITIONS-Condlllonsconlrlbuling to the death but not resulling In the underlyingcausagivan In PARTI. 19.WA5 MEDICAL E%AMINER
OR CORONER CONTACTED?
(~e
~ Decedent has pacemaker x~ res ^ No
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~i ~,~s 20. IF FEMALE:
' TL)}dJ¢I prognanl wlthln pest year
^ Pregnant el lime of death 21a. MANNER OF DEATH
XA' Nelurel ^ Homicide ~
^ Accidenl^ Pending Invesllga0on 216.IFTRANSPORTATIONINJURY
^ Driver/Operator
^ Passenger 21 c. WAS AN AUTOPSY PERFORMED?
^ YES ]{}~J NO
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r~yy,,
",'Als~~rj
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^NOl Pregnant, but pregnant wllhin 42 daysoldealh
^ Nol pregnant, but pregnan143 days lot year belora death
^Sulcide ^Could not be delermined ^Pedeslrlan
^ Oiher (Speclly)
21d. WEREAUTOPSYFINDINGSAVAILABLETO
,
COMPLETE CAUSE OF DEATHI
p
~E ^Unknownllpregnanl within the Paslyean __-- -___ _.__-,-_-___-__ _ _"^YES-' ^NO -
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T"fl 22arUAlEpF.INJURY (MO., Day,Vr.) 22b.'fIME OFINJURY ,~22a PLACEOF INJURY'Al home,term, street, lactary, olllc¢bullding, conslrucllon site, etc. (Speclly)
m
22d,INJURY ATWORK7 ~ 22e. DESCRIBE HOW INJURY OCCURRED
~F~ ^ YES ^ NO
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"'37+~~
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221.LOCATION OFINJURY-STREETS NUMBER, APT.NO.. CfiY/lOWN STATE ZIPCODE
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23e. DATE OF DEATH (MO., Day, Yr.) z> 24a. DATE SIGNED (Mo., Dey,Yr.) 24b.TIMEOFDEATH
z
a ~ a ~ ~ Dec . 4 2006 9:00. .a rn
ay aNp
m> 23b. DATE SIGNED IMo., Day,Yr.) 23c.TIMEOF DEATH R> 2dc.PRONOUNCED DEAD (Mo., Day, YrJ 24d. TIMEPRONOUNCEDOEAD
vx
o mo ( m E ~~~ Dec. 1, 2006. 11:01 a m
°.9°- 23d. TO the bast of my knowledge, death occurred al the llm¢, dal¢and place, ~ dwzp 24e.Onlhe basis of ¢xaminalion and/ nvesllgallon, in my opinion death occurred el
a ~ end due to the cause(s) staled. (Signelure end Tills) • c ¢ ~ the ' e, dale plat and d o Iha cause(s) slated. (Signelure end Title)
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' 25, DIDTOBACCO USE CONTRIBUTETOiHE DEATH? 269. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
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!! ^ YES ~ NO ^ PROBABLY ^ UNKNOWN ^ YES &1 NO' Nat Appllcabla I126a Is NO '^ YES ^ NO
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27. NAME,TITLE ANDAODRESS OF CERTIFIER(PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY)(Typeor Prlnl)
Michael G. Gilmour, De Adams Co. Att , P.O. Box 71, Hastin s, NE'69002-0071
`
~11~ 28a.REGISTRAR'SSIGNATURE
J.G 7p 25b. DATE FILED BY REGISTRAR (Mo., Dey,Yr.)
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