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The document filed
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Date ials
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RD. COMP ~~ `~` ~
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The West Twenty (20) feet of Lot Seven (7), and the East Forty
(40) feet of Lot Eight (8), in Block Two (2) of Westland
Subdivision to the City of Hastings, Adams County, Nebraska,
according to the recorded plat thereof
/~z
~i);t
ADAMS COUNTY, NE
INST. N0. ~I~~ ~ 5 ~ 9 9
Date la'1 •07 Time /~~ a~pn'1
`,
TER OF DEEDS
'.STATE OF NEBRASKA ,, ~ Q U ~' S 4 ~ ~
' % WHEN THIS COP-Y CARRIES THE.RA/SED.SEACOFTHE NEBRASKA HEALTH AND HUMAN SERVICES
SYSTEM; lT CERFIF/E$?HE BELOW TO•BE A'TRUE'COPY OF THE ORIGINAL RECORD ON FILE WITH
THE~NEBRASKA'HEALTH'AND: HUMAN'SERVICES SYSTEM: VITAL STATISTICS'SECTION, WHICH /S
THE°L'EGAU',DEPOSITORYFOR VITAL RECORDS. . `• '/J/ //"J~y~
DATE OF ISSUANCE 'Jc/ ;"",'(! :~
Q~QV , ~ • `~ -2007 1 ~~~aTANLEY S. COOPER-
' . , - f - ASSISTANT STATEiREGISTRAR: ,
- .LINCOLN, NEBRASKA ':' .~~~ ~ ~ ~ ~~ HEALTH~AND'HUMANSERV/CES-
STATEOF NEBRASKA DEPARTMENTOF HEALTH AND HUMAN SERVICESFINANCEANDSUPP08J
Am ..A A.TI.........1. ,...19 nnn~ .. e+rra~-r .... ~~._.. r ~ /111 ~1 A'(l.. '.
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I. DECEDENT'S-NAME (Flral; ~ Middle, Lael,~ ~ Sulllx)
Ma
O Z
b
d 2. SEX. 3. DATE OFDEA Mo., Day,YL)
ry
u
ro Female September2007
4. CITY ANDSTATE OR TERRITORY, ORFOREIGN COUNTRY OF BIRTH 5e: AGE-Last Blrlhtley Sb. UNDER 1 YEAR -Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo.. Day, vr.) ,
.. - (Yro.) ~ MOS. :DAYS HOURS. MINS. ~ ;
Juniata; Nebraska'. gq
August 6, 1913
7. SOCIAL SECUFIITY NUMBER -' Be. PLACE OF DEATH ,
505-70-9301 HOSPITAL: ^ Inpatlenl O
1HER:- ®~NUreing HOme/LTC ^Hos
lce Fadll
.¢
fib. FACILITY-NAME (II not Inslltutlan, glue street and numbeq p
ty
~~ , . ^ ER/OU~allenl ^:Decedenl'c Nome
s. Haven Home ; -0 ma ~ ~ ° ^ odrer s ea
~ ~
,, ~. ~ fic.,CITY,OR TOWN OF DEATH (Inclutle Zlp Code) ~ ' '~ ` ~ ~ ~ ~ ~ etl. COUNTY OF DEATH
`W
m Keriesaw 68956 Adams
,~ fia:RESIDENCESTATE
~ fib.000NN
fie CIN OR TOWN
Nebraska Adams Keriesaw
o Btl. STREETANDNUMBER fie. APT. N0 fi1. 21P CODE Bg.INSIDECITY LIMITS
m t00 West Elm Avehue,:PO Box 10 68956 Gd vas ^ No '
m
m
108. MARRALSTATUS ATTIME OF DEATH.^Marned ^Never Marned
'
'
10b. NAME OFSPOUSE(Flrsl. Mldtlle, Lect, SUIOx)Il wile, glue maldan name.
.: E~' .- ^Marned, but separated ®Wltldwetl ~ ^ Divorced ~^ Unknown
~, Joseph Zubrod
m
m- 11, FATHER'S-NAME (FIreL MlOtlle, Lasl, Sulllx) 12. MOTHER'S-NAME (Flrcl, _ Mltltlle, Maltlen Surname)
Mathias Pltz A olonia Bohr
13. EVERIN U.S, AflMED FORCES? GIVe dalesolservlce llyas. tAa.INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
(Yee, no, orunh:) NO ' ' ~ CUFIIS Zubrod
Son
15. METHOD OF DISPOSITION ~ 16a.EM CALMER-SIGNAL L'RE: 16b. UC
E
NSE NO. 16c. DATE (MO.. Day, YC)
®BUrlel ^DonaOon .~( ~
[
~'
~
/ September 2l, 2007
^Crematlon ^Enlambmenl. 1 d. EM Y,CREM RY OR OTHER LOCATION ~ CITY/TOWN STATE
^Removal ^Other(Speclly) ~ ~ ~ '
Parkvlew Cemetery Hastings Nebraska
'~ 17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clry orTown, Stale)
Brand-Wilson Funeral Home
505
N Bellevue
Has In
N
b
k I7b. Zlp Cotle
,
~
,
gs,.
e
ras
a 68901
CAUSE ~OF DEATH (See instructions and examples)'
16.'PART LEnlerlha chain of evenls~~tllaeaeee,ln)utlen, or camplliatlane--Iheldlrectly caused llieitlaelR DOINOT enter lerminal.events eucti as cardlabegeaL APPROXIMATE INTERVAL
respiratory erresh orvenmcularllbdtlalbn wllhout showln the etlol ~ '1 '
g ogy.DC NO7 ABBREVIATE. Enteronly one cause ariellne.Atltl atltlltlonal lines lfneceaeary. 1
IMMEDIATE CAUSE:
~
I onset to death
.1 1/,' . ~
J~
(8)
~
I
IMMEDIATECAUSE(Ftlel
QQ}.,v 1 (~, ~MA~~
(9 aA_ Q6 Ty cT(~
tlloaeee areentltlbnneutllrp° DUE TO, Ofl ASA CONS UENCE OF:" 1 onset to death
~
hdesth)i
, - ~ ..
p.
~
Sequpnllelty llalcontllllona, ll •ro)
.~ - 1
I
any, leadingb Neceuca tlgtetl DUE TO, OR ASAGONSEOUENCE OF: I oneel to deaN
on fine a:
I.
. EnIaMUNOERpINOCAUSE
(tlloeafe or ln)IayM16111e1ed lc) I
N
t
`
:
v' a even
s rvauAing hdse0t)
DUE TO.OR ASA CONSEQUENCE OF:
~. ~ 1 ansel to death
`
. g .. i
Ic:....
~ .
?.q' `1B.iPARTIIr..OTHERSIGNIFICANTyCONDITIONS-COndltlons conldWting to the tleath but nalresulOnBln lheundertylnd causeprvenin PARTL. 1g. YIASMEDICALEXAMINER~
'; OR CORONER CONTACTED?
^ YES ^ NO -
W
~'~
20 IF FEMALE: ~
Nol'
re
nanl wllhl
l
.21e.MA NEfl OF DEATH
l~alure4 ^HOmlade
21b.IFTRANSPORTATIONINJURY
^DtlvetlOpemlor
21C. WAS AN AUTOPSY-PERFORMED?
;~ g
,p
n Daa
year
~~ ~
~
111 ~~-
^ y~~.,,,///
^ YES ]p NO
U [
- ~
.
Pregnantal tldle of Cealh fl
~ ^Accidenl^Pending lnveatlga0on Pasaenger /-
~.~ ^
NOt pregnant, but pregndnl wllhln 42 da a of death
- y ^ Petlesltlan
2td
WERE AUTOPSY FINDINGS AVAIIASLE TO
[m,
m. ~ -
_'^NOIpreOnant,bN Pregnant 43days lotyeaibeloretleah ^SMdOe ^COUltl not be tletermined ^OVler(Spedly) .
COMPLETE CAUSE OF DEATH?
E... ^ Unknown ll Dregnenl wllhln the peel year ~ ~ _ , ^.YES,,. .^-NO .,-
L°y 22a. DATE OFINJURY (MO., Day, Vr.1 22b. TIME OFINJURY 22c. PLACE OF INJURY-Athome; term, slregl, laclory, olOCe bulltling, conslrucllan site, etc. (Spedty)
m uI
,F.
'22d.INJURY ATWORK7,. (
22e: DESCRIBE HOW INJURY OCCURRED
U.YES ^ NO .. i I
c
22t. LOCATION OFINJURY-STREET6 NUMBER,APT. NO. .CITYROWN STALE LPCODE
' i '
23a. DATE~OF DEATH o., Da ,YC) t 17 zs 249. DATE SIGNED IkIO., Day;Yr,) 2
~
~
~ 4b.TIMEOF DEATH
~
2UU7 ~~s -
2~Ati~
A'~
¢ m
~N. ay.0
-
s> 23b. DATE SIGNED Mo,;D
o y. c) 23c: TIME
O
FDEA
21c.PRONOUNCED DEAD (Mo.; Day,YL)- 2
TH - ~iG 4tl.TIMEPRONOUNCEDOEAD
.
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/
;
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E- >-z, .. ~ m
$ v 230.70 the beet of edge, death occurred a he Ome, date and lac ~ w i O - 24e. On the balls of examna0on entllorlnvastlgallon, In my aplnlon death occurred al
F « antl tlue to Ih a s) alaletl, (~I aWfa a a ¢ U Ne gma, tlate and place antl due to me cause(s) staled. (Slgnalure antl TIUe 1
a ~~. ''ate
u o
25. DIDTO&1000 USE CONTRIBUTETO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED'+ 26b. WAS COPISENI GRANTED'?
^ YES I~'~NO-: ^ PROBABLY ^ UNKNOWN ^ YES ~ NO Nol Applicable 1126a ie NO ^ YES ^ NO
27. NAME, TITLE ANDADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Tf~e orPnnl)
David R.'. Little, MD, 2115 N. Kansas, Hastings, NE 68901
28a, REGISTRAR'S SIGNATURE f 2fib. DATE FILED 9Y REGISTRAR (Mo., Day, Yr.l
~• SEP 2 6 2007
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