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Home My WebLink About20075315 ~" ~~~ NUM PGS~~ ~ ~ ~ ~~ NE U NTY O ADAMS ~oc TAx~ cK~ ~ ~ - ~ F~4 F ~ r s ~ ~~ ~~ ~ ~ 1L_cK#~_ zoo~s3~s A e~ ~. INST. NO. ~+ 11 ~ ~ e CHG ACCT # RET FEES: -CASH R.O.D. CK# Datel~ 5 0 ~ Tif118 ~~ `r~ FYI arcs ~ m~ RfTU ~ - ~ ~ ~ ~ J NUM _ ~ec~. S„h ~.'s~iai~ y~~/~Z~J ~~`~Mr ~ Rt __ ~l~d-} ~ .tl~ tad9~. RD. COMP %is- o REGISTER OF DEEDS COMPARE CADAS - AO ~ TO: ADAMS COUNTY RE GISTER OF DEEDS ;% PLEASE INDEX THE ATTACHED. DEATH CE1tTIFICATE OF ELSIE H. NYCE AGAINST THE FOLL OWING DESCRIBED PROPERT Y: A portion of Lot Twenty-two (22), Beck's Subdivision, commencing at the Southeast corner of said Lot Twenty-two (22), runming thence North 15 feet along the east line of said lot, thence West 44 feet 6 inches to the point where said line intersects the south line of said Lot Twenty-two (22), thence easterly along the south line of said lot to point of beginning; and All of Lot Twenty-one (21), Beck's Subdi"vision, except for a tract commencing. at the Northwest cornier of said Lot Twenty-one (21), thence south along the west line of said lot, a distance of 12 feet, thence east a distance of 41 feet 6 inches to a point intersecting the north lot line of said Lot Twenty-one (21), thence westerly in a straight line to place of beginning. A11 of which is located in the City of Hastings, Adams County, Nebraska. .. 1 0 ~o~ ., i tk '.. ~; ,:.._ i. ~' : ;~~ . ,; ... '~ STATE OF NEBRASKA' ;~ Q Q!'! rJ e) ~. J WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OFTHE ORIGINAL RECORD ON FILE WITH THBNEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION;:,WHICH lS- THELEGAL DEPOSITORY FOR VITAL RECORDS. "` ~` r //'/J~/~J u DATE OF ISSUANCE ~ ~ , n ,III I .,:"" ~ 0 i~u 1 ,' i ,y II,, r f~UI9 oD ~- ~~N~ ,, TANLEYS ,COOPER; 1 , - OV 7 D ASSISTANT STyT,E,tREGLSTRAH I ~ ~ c, ' LINCOLN, NEBRASKA ~ ~ HEALTH AND HUMAN SERVICES' # ~~ ;i r ,. ~(..v it ~` `>i blr . ~ STATEOFNEBRASKA-DEPARTMENTOF HEALTHAND HUMAN SERVICES FWANCE AND SUPP~ a~7Fi ~l"~~, ' ~ CFRTIFIC~TF nF IIFATH ~ `~' :'>:6 ` .n ~~;` f I I' e 1. DECEDENT'S-NAME (Flrsl, ~ Mltltlle, Lasl, _ Sulllx), 2 SEXr,'~, I,r ~~{~ -,.-. ~!J~DA1'E OF-0EATH (MO Day, Yr.) Elsie H Nyce Female, °'Nouember~2'1 `'2007 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5s. AGE-Leal Blrlhday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY y610ATE OF BIRTH (Mo., Day, Yc) ' ~" ~~ Campbell Nebraska (Yrs.) MOS. DAYS HOURS MINS Y 'y F , i! 90 October 18, 1917 ~l 7. SOCIAL SECURITY NUMRER q' Ba. PLACE OF DEATH _ - 522-10-4008 HgSp1T[yy:' Olnpatlenl ~1F& ~ ^NUrsing HOme/L7C ^Hospica Faclllly Bb, FACILITY-NAME (II not Institution, give slreal end number) ~ ERlOUIDellenl ~ Decetlenl's HOme Mary Lanning Memorial Hospital ^ 001 ^ONer (Specily) Bc, CITY ORTOWN OF DEATH (Include Zlp Code) Bd. COUNTY OF DEATH ^,' Hastings 68901 Adams iJ 9a.RESIDENCE-STATE. eb.000NTY 9c.CITYORTOWN :{{'; Nebraska ' Adams Hastings S 9d: BTREET AND NUMBER ~ ' Be. APT. NO BL ZIP CODE gg. INSIDE CITY LIMITS k 1504 Crestmoor Drive 68901 X] Yes ^ No 10e. MARITAL STATUS AT'fIME OF DEATH ^ Mariled O Never MarrieU 10b. NAME OF SPOUSE (FIrs1, Middle, Lasl, SulllxJ II wile, give maltlen name. ~^Mewled, but separated Widowed ~Dlvorcetl ^Unknown Merlon Nyce (dec) ., ii. FATHER'S-NAME (Flrsl, Middle, Lasl, Sullix) 12. MOTHER'S-NAME (Flrsl. Middle, M¢Idan Surname) ~ ' ~ .Alexander .. Koch ~ ~~ Katherine ~ Rahn p p YI~ 13. EVER IN U.S. ARMED FORCES7 Glva dates of service llyes. 14a.INFORMANT-NAME ~ 14b. RELATIONSHIP TO DECEDENT (Vas, no, or unk.) No Richer N ce - ~ ~ Son 15. METHOD OF DISPOSITION i6e ER~ A 16b. LICENSE NO. 18c. DATE (Mo., Day, Yr.) ~BUlial ODOnallon 1189 November 26, 2007 ^Cremallon ^Enlombmenl 16tl. EMETERY, REMAT VO OTHER LOCATION CITY/TOWN STATE ~I ^Removal ^Other (Speclly) Rosedale Cemetery Rural Hall County Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Cily orTOwn, Slate) 1225 North Elm Avenue 176.ZIp COde ~ ~ Ho me Livin ston-Butler-Volland Funeral 68901 Nebra H astin s s ka 1 .. . } ( ~+ y .I. )n y..3. .., ~ ~ ~.er ~r~,~{t yYy~ j. `MMM yy~y ,rj gq~1 ~1) '.. ~ 1~'' IAr. ~j( cr n ~ is ~ r u (' , . ~ ~~ ~ ' ~ ~ ' ~ ~ 4 ~ .F I ,,, f :r.. . , . ~ 1 .1 G t . e~. "$i°IAi S S " fl'r 1+.'.I `,1 ~IIff 'EJTKi FIL/ . ~'a,Jl .....r 11A I( i6. PA RT I. Enter Iha chain ¢I events-dlseeses, Injuries, or complicallons-Thal dlreclly caused Iha tlaalh. DO NOT enter terminal events such es cardiac arrest, APPRO%IMATE INTERVAL I ' fasplralory arrest, ar venlrlcular librlllallon without showing the ellology. DO NOT ABBREVIATE. Enter only one cause onellne. Atltl eddllionel lines ll necessary. I i IMMEDIATE CAUSE; - l onset to death I ~, IMMEDIATE CAUSE (Final f~ disease or condlllon resulllnB DUE TO, OR ASA CONSEQUENCE F: I onset to death ~ ,~, hr death) I . I i~ Saquenllelly list condlllons, it (b) I I any, leading to the cause listed DUE TO, OR ASACONSEOUENCE OF: ~ I onset to death on line e. I ~. ~ Enlerlhe UNDERLYING CAUSE (tllseaae or lnjurythetlnllleletl ' (c) I Ihaevenlsrmullingin tlaalh) ~~DUE TO, OR ASACONSEOUENCE OF: ? onset to tlaalh IABf I k, (~ I 18. PART ILOTHER SIGNIFICANTCONOITIONS-COndlllonscanlrlboling to the dealhbul nolrasulling In the untlerlyingcauaepiven In PART I. 1g. WASMEDICALEXAMINER vI ~ OR CORONER CONTACTED? ~ ~ ~ ^ YES ~ NO y y 26. IF FEMALE: 21 e. MANNER OF DEATH 21 b.IFTRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORME07 v { ' fB Nol pregnenl wllhin past year alJelural O Homicide ~ ^ Driver/Operator - ~ ~ )? ^ Pmgnanl al Ilme of death ^ Accidenl~ Pending Invesllgalion ~ Passenger yE5 NO f ' ^ Nol pregnenl, but lirognenl within 42 days of tlaalh ~~ ^ Suicide O Could not be determined ^ Pedeslrlan 21d. WERE AUTOPSY FINDINGS AVAILABLETO ~ (J Nolpregnanl, bulpregnenl43dayslol yearbeloredealh ^ Other (Speclly) COMPLETEOAUSEOFOEATH7 ' ~ Unknown ll pregnenl wllhln the pest year O YES F1 NO ) 22a. DATE OF INJURY (Mo., Dey, Yr.) { 226. TIME OF INJURY m 22c, PLACE OF INJURY-AI home, term, slreal, lactory, ollice building, construction site, elo. (Bpaclly) t 22d.INJURV ATWORK7 22a.0ESCRIBE HOW INJURY OCCURRED ~~ ^ YES ^ NO ; 221. LOCATION OFINJURY-STHEETB NUMBER,APT.NO: ~ CITY/pOWN ~ STATE' ZIP CODE i .. ~ - 23a, DATE OF DEATH (MO., Day, Yr.) z> 24a. DATE SIGNED (Mo., Oey, YrJ 24b.TIME OF DEATH 'as November 21, 2007 a`-u= U 2 m E ~ a 23b. DATE SIGNED (Mo., Day, Yr,) aa~ v N 23a TIME OF DEATH m i ~ 21c.PRONOUNCED DEAD (MO., Day, Vr.) '' 24d. TIME PRONOUNCED DEAD I November 21 2007 i E o 11:39 a m Ew~i ' m d ' m'a 23d. To knowl¢dga,:dealh occurretl el the lime, dale and place ~w~0 24e.Onlhe basis of examination and/or lnvesligellan, in my opinion tlaalh occurred al S a ~ du to the ca s staled, (S n Band Tllla) • a ~.p Iha lime, tlele entl place and due to Iha cause(s)sleletl. (Signature and Tllle) ( 25.OIDT08 USE CONTRIBUTETOTHE DEATH? 28e. HAS RGAN OR TISSUE DONATION BEEN CONSIDERE07 26b. WAS CONSENT ORANTED7 U YES C%NO ~ PROBABLY U UNKNOWN ^ YES C%NO Nal Applicable 1128a Is NO ^ YES ^ ND. 27.NAME,TITLEAND ADDRESS DF CERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY)Rype¢r PrinQ ~ NOrt t. osep ' Michael D. Matthews, ER RM Plary Lanning Memorial Hospital, Hastings, Nebraska 68901 2Ba. REGISTRAR'S SIGNATURE ~ 26b. DATE FILED BY REGISTRAR ~Mo., Day, Yr.) 2 9 2007 , . NOV ~r d n f~2.