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ADAMS COUNTY, NE
INST. NO. `~L~D~"~J4b5
Date a- 7-n7 Time a'~Oa ~
. ~,
TER OF DEEDS
NUM: ~e/~ll' rJiifi B/.~ o~ ~i~ s ry
RD COMP: cL~_~ ~ oi.
COMPARE:_ / G+~i
CADAS; - AO /
IZCSEItVED FOR REGISTER OF DEEDS ItECORDING,SPACE
ADAMS COUNTY NE
Got Light (9), Block two (2), Hersh subdivision to the village of
Kenesaw, Adams County, Nebraska, according to the recorded plat
thereof.
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_- ~ :.' STATE OF NEBRASKA .. ; ~ { ; ~;~ ~'• ~ 2
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'WHEN THIS COPY CARRIES THE RAISED SEAL OFTHE NEBRASKA HEALTH AND HUMAN SERVICES
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, SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE'OR/G/NAL RECORD ON FILE WITH
"' THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM; VITAL STATIST/CS SECTION, WHICH IS
i 2 ~ - THE LEGAL DEPOSITORY FOR VITAL RECORDS.
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OCT` 2:6'2007 ~ •.~'', ti t TANL6Y(S",000P~R~',al
•' - , ~ - ASS/STANT'STATER€G/STRAR~`I,+.
.• LINCOLN, NEBRASKA s HEALTH AND'HUNIAN SERVICES, ++q~ ~ ~ '
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ESTATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE'AND SUPPOF~
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CERTIFICATE OF. DEATH 4;k~
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'. 1. DECEDENT'S-NAME (First,' - ~ Middle, ~'Lasl, ~ ~`~ Sulll%) - 2~SE%J u .. A.^.1
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~ 3 DATE~OF DEATH:(MO ,Day Vi )~F ',,~~ -
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Lester Williarti Oelschiager ~ ~ u
~' Mele
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2007": ;'?~ l i
Octobe`r;:18
4. CITY AND STATE OR7ERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa.AGE-Last Blrlhdey 56.UNDER (YEAR ~5c:UNDERr1•DAYi~3 6'DATE OF BIRTJi (MO 'Diiy Yr ), .:
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(Yn.) MOS. DAYS HOURS , MINS ~ + ~
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25 )~~a~,;
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• Hansen, Nebraska 82 ,
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7. SOGIAL SECURITY NUMBER ~ _ ''I ~k 1~( ;:!'t ~t' ,
Ba.PUCE OF DEATH '
523-34-4189 I A :. ~ InpaBenl 4-1E6.'"' ^'NUrsingHOineaTC UHOSpiceFedlity
'~ Bb. FACILITY-NAME (II not inslltutlon, give street and number) O ER/OUQtallenl ^ Decedent's Home
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;Mary Canning Memorial Hospdal'+
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'71.-.. - U1 DOA ..... .nsU~OdrerlSpedty)- ...- - '.
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J ~BC: CITVORTOWN OF DEATH (Indutle Zlp COtle)1 - Bd.000NTYOF DEATH ~ ~ ,
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Hastings 68901 - Adams "
Z Ba.RE51DENCE-STATE ~ 64.000NTY ~ 9a CITY OR TOWN '
~. Nebraska' Adams Kenesaw
o Bd, STREET AND NUMBER ~ ~ Be. APT. NO 91. ZIP CODE eg. INSIDE CITY LIMITS
= 500 N Wavne _ " 68956 ~ YES ^ No
m tOa. MARITAL STATUS AT TIME OF DEATH-~Marrletl UNever Marnetl 10b, NAME OF S?OUSE (First R!!dtlle,last, SUlll%)Il wlte, glue maltlen name:
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^ Marned, but sepaatetl U Widowed ^ Divorced U Unknown
o Lavergne Fink
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I1. FATHER'S-NAME (First, ,Middle, Lasl, Sullis)
12. MOTHER'S-NAME (Fl rsl, Mitltlle, Malden Surname)
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William Oelschlager ~
Margurite •Frese'
13. EVER IN U.S.ARMED FORCES? Glve dales of service llyes. I4a.INFORMANT-NAME ~ ~ 14h. RELATIONSHIP TO DECEDENT
(Yea, no,orunx.) Yes g_5_41 _ _ Lavergne Oelschlager Wife
15. METHOD OF DISPOSITION I6a.EMBALMER-SIGNATURE I6b, LICENSE NO. ~ 16c. DATE (MO., Day, YC) -
^Budal~ "UDOnatlon Not Embalmed. ~ ~ ~ October 22, 2007
®Crematlon. ^Entombment i6d.CEMETERY,CREMATORY OR OTHER LOCATION ~ CITYI TOWN STATE
' ^Removal ^Olher(Specuy) - ~ '
Central Nebraska Crematory Service ~ Gibbon Nebraska
17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty orTawn, Stale)
Jackson-Wilson Funeral Home, 209 N. Smith Ave, PO Box G, Kenesaw, Nebraska 17b. Zlp Code
68956
CAUSE OF DEATH'(See instructions and examples)
1B.'PARTLEnlerlhe chain of events-diseases,In)utles, or wmDllwtlans--that dlredly caused the tlealh. DO NOT enter terminal events such es cardiac arres4 APPROXIMATE INTERVAL
I
resplmlory anesl, arvenUlcular llDUllallon wkhoul showlrg the egology.DO NOT ABBREVIATE. Enleronly one cause onallne.Add addlgonal lines ll necessary. I
IMMEDIAr CAUSE: ~ ~ l onset to tlealh ,
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IMMEDIATECAUSE(Fhel
dheesea condhnmecuging~ DUE rO,OH ASACOHSEOUE;ICE OF: I onset to tlealh
' hdeoth) 1 -
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Sequenllelty llatcandlllons, ll
erry,leading to Neceuce gated pUE TO, OR ASA CONSEQUENCE OF: ~ I onset to tlealh
on line a. ~ ~ I
Enla a,e UNDERLYWOCAUBE ~ 1
(tllseese or lnlwY Nelhltlaled lcl -
tlieeventsreauginghdeam) DUE TO,OR ASACONSEOUENCE OF: ~ .. I onsetto death
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I a. PART II.OTHER SIGNIFICANT CONDITIONS-Condlllons conldW gng to the deaN Wl not resulgng In the undertying cause given in PART I. 18. WAS MEDICAL EXAMINER
' ~ OR CORONER CONTACTEDo
':. .:' '. '... ~... - - .-. i' ~ ~ U YES NO'
' •¢ 20. IF FEMALE: ~ - ~ -
: 21a. A NER OF DEATH 21D.IF TRANSPORTA710NINJURY 21 c. WAS AN AUTOPSY PERFORMED?
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^ Nol pregnant wlminpastyear ~alura6 l~Homldde ^DdveUOperator
U YES ~NO
v- r , U Passen
er ,
^ ^ AccltlenlU Pending Investlgagon g
U ~ Pregnant al gme of death
^ Nol pregnant, DUl pfegnanl wllhln 42 day8 of tleatll
^SUIUde ^COUld nolbe tlatatminetl ^Petlestdan 21d. WERE AUTOPSY FlNDINGS AVAILABLE TO
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^ Nol Dregnant, but Dregrant 43 days totyearbelore deaUl UONer(Spedly)
COMPLETE GAUSS OF DEATH?
- n -.^ Unknown It pre0nanl wlthln the past year . ~ -._ ^ YES U NO
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22a. DATE OF INJURY (MO., Day, Yc)
22b. TIME OF INJURY
22c. PLACE OF INJURY-AIDOma, term, sireeL taclory, olgca bulltling, conslrucgon silo, eta (Speclty)
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22d.INJUHY ATWORK7 22e. DESCRIBE HUW INJURI' OCCURRED
U YES ^ NO
221. LOCATION OFINJURY -STREETS NUMBER,APf. NO. CIiY/TOWN SWTE ZIP CODE
24a. DATE SIGNED (MO., Day,Yr.) 24h. TIMEOFDEATH
23e. DATE OF DEATH (MO., Day,Yr) ~ -
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ga ~ ~"October 1 8, ' 2007 c oQ m '' -
8'y 23b. DATE SIGNED IMo., Day, Yc) 23c. TIME OF DEATH use 24c. PRONOUNCED DEAD (MO.. Day, YC) 240.TIME PRONOUNCED DEAD.
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aa~ ~. 10:05 P m EA`>= m
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TO the besLOl my knowledge, death occurred at the Ume, date and place mw~ 24e. On the bads of exanlnatlon arMlorinveadgagon, In my opinion death aocurted at
23d
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my
a ~ the cause(s) stated. (Signature and Tlge) • o.p O IDs Oma, date and place antl due to the cause(s) slated. (Slgnatwe and Tlge)
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25. DIDTOBACCO S CONTRIBUTEIOTHE DEATH? 26a.HAS ORGAN OR TISSUE DONATION BEEN CONSIDEREDV 28D.WA5 CONSENT GRANTED9
^VES O ^PROBABLY UUNKNOWN YES ^.NO Not ApDllcahle 1126a IS N0 UYE$ NO
NAME TIT AND ORESSOFCeRTIFIER PHYSICIAN,CORONERSPHYSICIANOR000NTY ATTORNEY)(Typeof Pnnq
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'~erverrt
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- 2Ba: REGISTRAR'SSIGNATURE -~
~ d, 28b. DATE FILED BY REGISTRAR (MO., Day,Yr.)
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