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HomeMy WebLinkAbout20075633S.A.S E. NUM PGS DOC TAX CK# FEES /0.5o PD /D.Sp CK#LG3IL. ' CHG ACCT"# RET FEES: CASH _ .0.0. CK#_ REC'D~ - RETURN I Ill~lnll IIIVIIII81 RI~I II NUM ~9- ~-// RD. COMP ~ ~ ~=-sn COMPARE `~ ADAMS COUNTY NE FILED INST. NO.~ r ~ 6 3 3 Date l.? • 3I -07 Time a~ S ~}' ~~~~r~o~I REGISTER OF DEEDS ,~a r/E G~,~S.L-od yL CFlDAS AO ,~ - AFFIDAVIT OF MARITAL STATUS (NCLE 535) , STATE OF NEBRASKA, County of Jefferson, ss. COMES NOW, the. undersigned; being duly sworn; deposes and says that the undersigned knew the Decedent, she is the surviving spouse of the Decedent and that the. following information is true and correct: 1. Name of Decedent: John W. Karenbauer Date of Death: November 28, 2007 Domicile at Date of Death: Fairbury, Jefferson County, Nebraska Name of Surviving Spouse: ;Janet E.: Karenbauer: . 2. The Affiant is related to the Decedent.as follows: ..Spouse 3. There is no Federal Estate Tax, Nebraska Inheritance Tax or Nebraska Estate Tax due. ... . 4. Title to the fol lowing described real estate is held by the Decedent and the surviving spouse,of.the ;pecedenf. in joint tenancy, to wit: -; , South Half (S'/) of Section Twenty-nine (29), Township Seven 7 North; Ran'e Eleven 11 -West of the 6`" P.M., Adams O 9 ( ) County, Nebraska 5. As of date of death, the real estate has a assessed value of $318,450.00. 6. The Decedent and.Affiant were married as of date of death. There would be no Federal Estate Tax clue here due to the entire estate of the deceased being less than $2,000,000.00 and all property of the deceased passing to his spouse. Likewise, Nebraska Inheritance.Tax was repealed retroactive to January 1, 2007 by LB' 367. There isno Nebraska Inheritance Tax by reason of Nebraska Revised Statutes Section 77-2004. ,.. 7. A certified copy of the Death Certificate.pertaining to John W.. Karenbauer is hereto attached and made a part hereof by this reference. FURTHER AFFIANT'.SAYS'.NOT. SUBSCRIBED and sworn to~before me ~.,e.~ µ4-cEr~aAt r.~tnnvs~ar< of ~i:0raska RONALD R. GRACKLE My C9rnm. Exp. My commission expires: 7/4/2008 A(150) Misc NCLE535 2253 p2 ;. - " ~' - ' ~ ~ ~ "RONALD R. DRACKLE ~ " 417 "F" Sbeet - P.O. Box 12 Fairbury, Nebraska 88352-0012 (402) 72B-2228; FAX (402) 729-2807 I 0 ~ /~i r-< Bk . ' ~ STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERVICES .-~~~ ~ I'.P19T1 rIfsATC AC nC ATLI /. DECEDENTS-NAME IFlrat, Mitltlle, Lasl, 9u1Rx) 2. 9Ex ~. DATE OF DEATH (MO.,Day,Yr.) .John Wayne Karenbauer Male November 28, 2007 4. CITY AND 9TATE OP. TERRITORY, OR FOREIGN COUNTRY OF BIRTH 6e, qGE-Leaf Birthday 6b. UNDER 1 YEAR Bc. UNDER 1 OAY A. GATE OF BIRTH IMO., Day, Yr.) - pn.) MOS. GAYS ~ ~ HOUR9 MINS. i Kearney, Nebraska _ •, _ ` 56 -- ~ January 24, 1951 / , `7. SOCIAL SECURITY NUMBER ~ Be. PLACE OF OFATH ~ ~ ~ - . ;K 5D6=66-5966 - HOSPITAL• ©Inpatlenl ~ OTHER: ^ Nursing HomeILTC . ^ Hpeplee Faellity 'O Bb. FACILITY-NAME (1/not Inslitullon, give etree/ end number) ^ ERlOutpetlant ^ Deeedent'e Homo ' W o ~ Nebraska Medical Center-University ^' DOA ^ Ollien5peeity) J Be. CITY OR TOWN OF DEATH (Ineludo Zlp Code) Bd. COUNTY OF DEATH Omaha 68198 Douglas 2 90. RESIDENCE-STATE Bb. COUNTY 9e. CITY OR TOWN ' LL ,, Nebraska Jefferson Fairbury a y 9d. STREET AND NUMBER Be. APT. NO. 91. ZIP CODE /` 9g. INSIDE CITY LIMITS N ' c 1225 K Street 66352 Yea No ® ^ _ 19a. MARITAL 9TATU9 AT TIME OF DEATH ®Manletl ^ Never MaMed tOb: NAME OF EPOUCC (FI!st, Middle, Lesl, 9ufflsl If wife, glee maiden name. m ^ Merited, but aeporelad ^ Widowed ^ Dlvoreed ^ Unknown Janet Thaut n E _ if_FFATHER'S-NAME_(Fira4; _._Middle. Lnaq BNgx) --- -- ~ ---~ _ - 12 MOTHER'S-NAA!E (Ping 'Mltldle,' Maidon Sumeme) ~ Eu ene Karenbauer Florence Sprin er m 1J. EVER IN U. S. ARMED FORCES7 Give dotes of e_ervlce If Yee. 14a. INFORMANT-NAME ~ ~ ' 14b. RELATIONSHIP TO DECEDENT F (Yea, No, or Unk.) Np Janet Kar Bauer Wife i5. METHOD OF DISPOSITION iBa. EMBA NATURE 16b. LICENSE NO. 18e, DATE IMO., Oey, Yr.) ^ead.l ^oamnen ~ 2D07 ' December 5 , ®cmm.nvn ^Emememem ^nem¢ral ^ommi9peceH _ 18tl. CEMETERY,CREMAT YOR OTHER LOCATION CITYROWN 9TATE ' Lincoln Memorial Funeral Home ~ Lincoln - Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Sheet, Clty or Town, 9tata) 1Tb. Zip Code _ Gerdes Meyer Funeral Home, 2414 H.Street, Box #15, Fairbury, Nebraska 68352 _ CAUSE OF DEATH (See instructions and examples) - 1e.Pgftrl.Enterebe ceern IXavantr-tlleeuee, Inlurlaa,meompilcetlona-thee tllrtdly uusetl rae tleetM1. ee NOT mtervmlul a+ame.vchnuralscemtl, i APPRO%IMATE INTERVAL Atltl etldlBOnd Ilnu X mceuery. an. ene s V E t l t , . y ene uu e n er on IATE raaplntory emet, or venmaler nbdlletlon w11heN eheMnB IM ellolpBl. nq NOT ABBRE IMMEDIATE CAUSE:- r onset to death IMMEDIATE CAUSE (Final % , ~ tlleeese or eontlltlon reaulling a) ~ iU ~ ~ DUE TO, OR AS A CONSEQUENCE OF: ~ ~ onset to tloa h S¢quenllally Ilse conditlena, II b r /~ `,~~rL~~ I +^U~T /jr ~'~- , L~~^~'Y~-! --- any, leetling to lha reusr. Ileled ) Y`V - f = on line ¢. DUE TO, OR AS A CONSEQUENCE , onset to dehllr r r Enmr the UNDERLYING CAUSE ¢) ~ (dlse¢ae or in)ury Thal Inllleled the events reaulling in death) DUE TO, OR AS A CONSEQUENCE OF: ; onae! to death LAST I __ .. I _. ___.. .._ - ~. , OTHER SIGNIFICANT CONDITIONS-COntllUons I:ontdbuting to the death but noL reaulling In lh¢ undadying eauae given in PART L 7B. WAS MEDICAL E%AMINER PART B 18 . . OR CORONER CONTACTEDi ~ ' ~ ' (~ 1,. L /tiN ^ YE9 ~NO i ~ ~rh/T/"`a ~' .. .. d (/R~..J~t~i/ -~ W 29. IF FEMALE: 21e. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21a WAS AN AUTOPSY PERFORMED? r., ^ Nel pregnant wllhln past year is Nelursl ^ Homicide ^ Ddver/Operator W ^ Pregnant at lime of doelh ^ Accident ^ Pending Inv¢allgatlon ^ Pesaengm 21 d. WERE AUTOP911'PINDING9 AVAILABLE U ^Nol pregnant. bu[ pregnant wllhln 42 days of death ^ Suicide ^ Could not bb tlatarmined ^ PedesMan ~ ~ TO CBMPLETE CAUSE OF OEATIl1 Y ~ ^ Nol pregnenL but prognanl4B deya to t year baton death ~ ^ Olhar ISpaclfy) ^ yE& ~ NO ~ m ^Unknown II pregnant wllhln the peal year ~ sl a 0 2Ia. DATE OF INJURY IMO., Day, Yr.) 226. TIME OF INJURY 22c. PLACE OF INJURY-Al home, farm, street, faelpry, ofnce building, eonetrucllon elta, etc. (Speclly) ~ U. - ' m 22d. INJURY AT WORK? 32e: DESCRI9E HOW INJURY OCCURRED i F_ ^ YES ~ND I 221. LOCATION OF INJURY-STREET 6 NUMBER, APT. NO. CITYROWN STATE 7.IP CODE I ]Jo. DATE OF OEATN IMO., Day, Yr.) ~ Z 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF OFATH a''g /- ap'c77 $u~ m _ u yy PItONOUNCEO DEAD i 2J6. DATE SIGNED (MO., Doy, Yr.) ~ g 2~c. TIME OF DEATH Y O Tx 24c. PRONOUNCED DEAD IMO., Dsy, Yr.) 24d. TIME ~} 6 k>• ai a ' ° a ~ ~ .: ~j .. `j-~ 'j n a z (7L m E r - m D m0 22d tleellr ecrumed al the Ume, tlele end place u W = O To lire bast of m knowledge 24e. On the Basle of exeminatlon and/or InvasHgallon, in my opinion death oecuned , . n° a and due to the sa(e) elated: (Signaluro arM Tllle) y. ~ ~ et the lime, data and glees and tloa to the cause(s) slated. (SlgneNre and TIU¢) p ~ g C U ,.~~, ~/ - c u o 2&. OID TOBACCO USE CONTRIBUTE TO THE DEATH? E DONATION BEEN CONBIDERED7 28a. HAB ORGAN OR TI95U 3eb. WA9 CONSENT GRANTED9 'YES ^ NO ^ VRDBABLY ^ UNKNOWN a ^ 7ES Ip NO Nat Appllceble H 26a is NO ^ YES ^ NO M((E~~, TITLE AND ADDRE93 OF CERTIFIER (PHYSICIAN, CORONEnR'9 PHYSICIAN OR COUNTY ATTORNEY) (Type o//r Pdnt)L~ 'GP% P 27. N A CC"'7 1 ~ 1/~ / J ' (~ " - - - •~ . 6 ~ et. / /r.o~ ~dk rQs PO ~ ,_ ~Iv /, ~'~' 4JGL a. ., titi // ~ 28e. REOISTRAR'8 SIGNATU ,~~ 28b. DATE FILED BY REGISTRAR IMO., Oay,.Yr.) . t , ~," DEC 1 8 2007 ,~ - P .r a ~, ¢ It ~ ~~ , ,r/ f . 1 _ ,I ~Il. ''i~ r .. 'u ,.i Thts `cettffies.tllis document to be aarue copy of an original record on file with Vital Statistics, Douglas County Health Dept ,Omaha, Nebraska 'Certified copies must have a raised seal in th"e area to the left. Reproductions of this. greeil,cei-tificate are fiotl'egal copies. ,.., r, ------. Date Issued ~"~ ~ ,~ r, ~, :8 ~~ Registrar: ~', ( ~~- ~~'1r ~,, d of .Z