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Date Initial
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RD. COMP ~ ~ 9=~~ ~J,c~
COMPARE /g~
ADAMS COUNTY, NE
INST. N0. E~~®r1 rJ 6 ~ ~
Date ~ ~,~1-~7 Time =5S ~M
~,~' ~~~~
REGISTER OF DEEDS
LOT ELEVEN (11), BLOCK THREE (3), IMPERIAL VILLAGE ADDITION TO THE CITY OF HASTINGS,
ADAMS COUNTY, NEBRASKA, ACCORDING TO THE RECORDED PLAT .THEREOF
STATE OF NEBRASKA-DEPARTMENTOF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
-_. CERTIFICATE OF nFATH
I. DECEDENT'S-NAME (Flrel, Mltltlle, Leat, Sullix) 2. SE% 3.OATE OF DEATH IMa., Dey, YL)
Maxine E. Vanosdall Female Jan. 21 2006
<. CITVANO STATE OgTERRITORY,OR FOREIGNCOUNTRY OFBIgTH Sa. AGE-Lest Birthday Sh. UNDER1YEAfl 6c.UNDERIOAY B.OATE OFBIRTH IMO., Dey,Yr.)
Grand Island, NE (Yra.) 8D MOS: GAYS HOURS MIN3. NOV. D2, 1 925
7. SOCIAL SECURITY NUMBER Be. PLACEOF DEATH
506-26-8210 MOSPI7BL: X6a lnpallenl ~¢g ONUralnp HOmdLTC OHosplce Feclllry
Bb. FACILITY-NAME III not Inelllullon, give elreel end number)
Mary Lanni ng Memorial Hospital (]EWOUlpellsnl ^Oacedant'e Home
^ DOA ^ONer(Speuly)
Bc. CITY Oq TOWN OF DEATH (Include Zlp COtla) Bd.000NTY OF DEATH
Hastings Adams
Bs.RESIDENCESTATE 9b.000NIY Ba CITY OR TOWN
Nebraska Adams Hastings
Btl. STREETAND NUMBER 9e. APT: NO 9f. ZIP CODE Bp. INSIDE CITY LIMITS
291 3 West 7th 68901 )87¢ES ^ No
lOe.MARITAL3TATVS AtTIMEOF DEATH TC~arrled ^Never Merrietl IOb. NAMEOFSPOUSE(Firsl, Mlddla, Leal SUDlx)Ilwlle, Blue maiden name.
~Marrled, bw eepersled ^Widawatl ^Dlvarcad OUnbnown David ,Vanosdall
II. FATHER'S-NAME (Flrat, Middle, Laet, 6uflis) f2. MOTHER'S-NAME (Flral Mlddte, ~ Maltlan Surname)
Geor a W. Kra Mabel B it
13. EVER IN U.S. ARMED FOgCE57 Giva dates of service ll yea. f1a.INFORMANT--NAME tIb. RELATIONSHIP TO DECEDENT
(Yee, no, or unk.) No David Vanosdall Hus and
15. METHOD OF DISPOSITION tBe.EMBALMER-SIGNATURE ,, t6h, LICENSE NO. 18c. DATE IMO., OSy, Yr.)
^BUrlal ^Onneuan- No Embalmin -------- 'Jan. 23 2006
J~mmalbn ^Entombment tBd.CEMETERY, CREMATOgY OR OTHEq LOCATION CITY/TOWN STATE
^Remavnl ^o1h.rlsp.euy) WestLawn Crematory Grand Island NE
1h FUNERAL HOME NAMEAND MAILINGAODpESS (Slreel, City or Tawn, Slale) ... 1]b, Zlp Code
Brand-Wilson Funeral Home, 505 N. Bellevue, Hastings, NE 68901
13 PARTLEnler the cosh of evema.-tlisauee, Inlurlea, orcompllcetlons-that tlireclly ceased the deeU. DO NOTeniar lerminnl evanp each ea certllac erreat, APPROXIAMTE INTERVAL
I
neplmlory arrest, or ventricular Ilbrlllallon wilhoul ahowinp the allolo9Y.00 NOTABBREVIATE. Enter ontyane cuss on a line. Atld eddlllonal Ilnee 11 neceaeary. I
IMMEDIATE CA
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OUE TO, OR AS ACONSEOUENCE OF: 1 onset to death
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18. PART IL OTHER SIGNIFICANT CONDITIONS-Cantllllone conlribullnp to the death but oat msulllnp in Iha underlying cause given In PART I. 19. WAS MEDICAL E%AMINER
(N ^ ~~ Af ~ 1 ^ 5i'~
V V I~T' VLa-~ OR CORONER CONTACTE07
` ^ YES ~, NO
ZO. IF FEMALE: 21 a.M NER OF DEATH 2t0.1FTRANSPORTATION INJURY 21 c. WAS AN AUTOP9V PFAFORMED7
~Nol prapnenl within peal year ~,leluml ~Hanldda ^Drlvar/Opemlor
^PUaen ar ~ YES ~GJD
O prapnenl el lime of dselh ^ACCitlenlO Pantllnp lnveelipetlon 9
^NOt prapnenl but prapnenl w101n A2 tleye of death ^Pedealdan 2itl. WERE AU70PSYFINDINGSAVAIIABLETO
^SUlciae ^COUld not b. aeleMlned
^NOl prepnenl.butpregnenl /3 deye lot year belore tleelh ^Olhsr (Spa<IIyJ COMPLETECNJSEOF DEATH?
^'Unknown ll yrepnenl wllhln the past year ^ YES ^NO
22a. DATE OF INJURY IMO., Dey, YrJ 22b. TIME OFINJURY 22e. PLACE OFINJURY-Al home,term, elnel, ledory, dlllM hulltlinq, eonelrucllan alla, eta lSpeclly)
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22d.INJURY ATWORKt 22e. DESCRIBE HOW INJURY OCCURRED
^ YES ~ NO
22t LOCATION OF INJURY-STREETS NUMBER, APL NO, CGVROINN •• S]AE ZIP CODE
23a. DATE Of DEATH IMa., Oay,Vr.) 2Ia.0ATE SIGNED (Ma, Day, Yr.) 210.TIMEOF DEAtH
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'ia 23b, DATESIG-D(MO.,
eg//Yr.) 23a TIMEOFDFATH yi~ 21c.PRONOUNCEO DEAD(MO., Deg YrJ 2/tl. TIME PRONOUNCED DEAD
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E9 23d. TO the heal of awled9e, Oenlh o<curretl sl lha lime, dale end place $um1~0 2de.Onlhe besfsoi eaaminallon enNOrlnvestlAallon, In myopinlan death occunadal
E~ endtlus la lh se(s)6laled. (Slgyalure ndTille)•
¢U Iha Bma.dataendp!ace enddualo the aause(gsleled. (Sipnalure end Tllle)•
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25. DIOTOBACCO USE CONTRIBUTE TOTHE DEATH? 26e. MAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WA3 CONSENT GRANTED?
^ YES NO O PROBABLY O UNKNOWN ^ YES ~ NO Nol Applicable 1126a le NO ^ YES NO
27. NAME,TOLE AND ADOgESS OF CERTIFIER (PHYSICAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY( (Type or Print)
David R. Little, 2115 North Kansas Ave. Hastings, NE 68901
28a. flEGISTRAWS SIGNATURE 280. DATE FILED BV gEGISTRAq (Mc., Day, Yr.)