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--~_B.a N - G
The docum nt filed
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ase/are"not original.
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Date Ind
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ADAMS COUNTY, NE -?
INST. N0. F~~O'7 5 4 9 8
Date a- q-n Time 3~n'1
NUM ~esf/Q.~~ ~S'~~,G
RD. COMP x ,~ ~S~'O/
CD~JIPARE .~/ ~'
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The West 20 feet of Lot 7 and the .East 40
City of Hastings, Adams County, Nebraska,
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WHEN THIS-
-" DEPARTMENT
.._.BUREAU;"; QF~ i
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TER OF DEEDS
feet of Lot 8, Block 2, Westland~Subdivision, -
according to the recorded plat thereof
s c d r -.~ F ~,$ a i . ~.
'EAL OF'THEINEBRASKA}STATE`: ; ~
THE BELOW TO CBE A ,TRUE COPY ' " '
1 -
;THE ~3TATE~ DEPARTMENT OF.IHEALTH -
• _, r _ '.
TISTICS,AWHICH'IS THE;`LEGAL DEPOSITORY FOR
* i ,. / - 4,
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` STANLEX .S.`::. _COOPER, DIRECTOR:
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- '-":: BUREAU' QF.VITAL:'STATISTICS.
STATE OF'NEBRASKA - DEPARTMENT OF HEALTH
.BUREAU OF VITACSTATISTIC$. ' ,
CERTIFICATE OF DEATH,:. % -~
1. DECEDENT -NAME FIRST 'MIDDLE LAST 2 SEX 3. DATE OF DEATH rMmm, Day, Year)
• Jose h L. Zubrod Mali - Jul 3, 1992
' ~. CITY AND STATE OF BIRTH fe noNn USA, name camby) Se. AGE -Leal BlnNdey - E. DATE OF BIRTH (MPnm, Day, YsL)
(Yrs.1 56. MO5.1 GAYS Sc. MOUR51 MINS.
' -- -Holstein , Nebraska 87_.-- -.;- --~- ---_,-~;-- ,-~~ -•-Se bember--14, 1904.•-- -
iT. SOCIAL SECURITY NUMBER BL PUCE OF DEAtH-=-- "-` '- - ~ ` - ~ -- + '^ -- -~ -
HOSPITAL. ^ Inpaaenl ^ ER/Outpaaenl ^ DOA -~~ ~ _ - ~~ ~ ~ ' ~ - ~ - - _
508-44-5193 ~ THER: ^ Nuninp Home jQ Residence ^ Omar (SpsriryJ
66. FAGLITY - Name (I! nd IrtsliMlon, pies abssl aM num6sr) Bc. CfTY, TOWN OR LOCATION OF DEATH Bo. INSIDE CITY LIMITS M, COUNTY OF DEATH
(Spec/ry Yu or No)
2717 W 9 Hastin s es Adams
Da RESIDENCE -STATE es. COUNTY Bc. CITY, TOWN OR LOCATION ea. STREET AND NUMBER (Inclutlilp ZiP Cods) a. INSIDE CITY LIMITS
' rSPSeiN Yee or NaJ
NE Adams Hastin s 2717 W 9 68901 es
10. RACE - p.D.. W6ite, Black Amerken Indlen, I I. ANCESTRY lap.,llellen, Meaiun, German, dc.1 12. MARRIED,NEVER MARRIED, t3. NAME OF SPOUSE In wits, give maiden nemsJ
sm.1,(SpselryJ (Speedy/ WIDOWED, DIVORCED (SpaciryJ
• Cb
White ~r
married Ma Pitz
1/a. USUAL OCCUPATION (Give AiM o! wwA don e dunnp moat I16. HIND OF BUSINESS INDUSTRY
d wwMrp k'H, even i! mdred)
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b\~ Ebmenury ar Secondary 10-121 i Cdleps rl a or $q
farmer Agriculture g
18. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER -MAIDEN NAME FIRST MIDDLE UST
Cyria Zubrod Elizabeth Luers
I8. WAS DECEASED EVER IN U.9. ARMED FORCES7 1D. INFORMANT -NAME -MAILING ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP1' ,
IYas, 11q a] unk.1 18 yn, pive war and deln d eervlceal
no Ma Zubrod-2717 W 9-Hastin s NE 68901
20e. BURIA Dlamellan,Removal, 206. DATE 10c. CEMETERY OR CREMATORY -NAME 20d. LOCATION CITY OR TOWN STATE
Donal n
ial Jul 7, 1992 Parltview Cemet Hastin s NE
21. LMER -SIG ATURE LI ENSE O. 22. FUNEML HOME -NAME AND ADDRESS ISTREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
Brand-Wilson Mortua -505 NBellevue-Hastin s NE 6890]
DIATE C _ IT E~N.^T~ R ONLY NE CAUSE PER UNE FOR 161. AN01c11 I Interval 6aMean angel entl deslb
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OUE T0, OR AS A CONSEQUENCE OF: I Inlarval between tinsel and death
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DUE TO, OR AS A CONSEQUENCE OF: I Interval beAeen oneat and deem
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OTHER SIGNIFICANT CONDITIONS - CondlHOn! camrlbutlnp W deem 6u1 not relaletl PART III IF FEMALE. WAS THERE A 2a. AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
PART
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(~l~ PREGNANCY IN THE PAST 3 MONTN57
(Spsciry,Yegw NOJ
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EXAMINE OR CORONERT
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~w~ ~ ` Yes ^ No ^ ~
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28n ACCIDENT, SUICIDE, H MICIOE, UNDEi., 286. GATE OF INJURY (MO..Day, Yr.J 28c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
OR PENDING INVESTIGATION (SpeafyJ ~ '
28e. INJURY AT WORK 281. PLACE OF INJURY - Al trome, farm, B6eaI, lactwy, 28p. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
(Speciy Ysa ar NoJ ~ emu 6ulMinp, etc. (SpsciyJ
2]e. DATE OF DEATH rMa., Day, Y
i.J 28e. DATE SIGHED (Mp.. Oay, Y~.) 286. TIME OF DEATH
S (`(~ ~j ^,
Z
3~~.~ / t. / 4- a3~3' M
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y 216
DATE 51 ED (a
sy
YtJ 27c
TIME OF DEATH
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PRONOUNCED DEAD
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E 21tl. To 16e std knowletlpe, tle curratl el maji a en ace
/I B ~ ~ 29a. On Ibs 6eaia bl eeaminalion aMlar investipalion, in my opinion tleatb accurretl el
uwapl eb(w. i
- g b ais lima, dne end place and due to IM causele) nslee.
SI nature sntl Tllle - ~ ~ Si newre and TiVe
29a. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 JOa. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? J06. WAS CONSENT GRANTED?
^ YES ONO UNKNOWN YES ^ NO ^ YES NO
31. NAME AND ADDRESS OF CERTI IER 1PHYSICAN, CORONER'S PHYSICAN OR COUNTY ATTORNEYI (Type w PdntJ
Da d Little 15 NKansas-Hastings NE 68901
3% R I J26. DATE FILED~r ~IFGIS'IRAo (~~~c/