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DocrAx CK# ADAMS COUNTY, NE
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CHG ACCT # 20080256 INST. NO `,~ 5 6
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_..~ ~~~101 RD. COMP .~~ REGISTER OE DEEDS
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TO: ADAMS COUNTY REGISTER OF DEEDS
PLEASE INDEX THE ATTACHED DEATH CERTIFICATE OF ROBERT CALVIN
SNELLER AGAINST THE FOLLOWING DESCRIBED PROPERTY:
The West Half (W/2) of Lot Two (2), Block Seven (7), College Addition to the City of Hastings,
Adams County, Nebraska
/ v~~,
STATE OF NEBRASKA
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, .WHICH IS
THE LEGAL DEPOSITORY FOR VITAL RECORDS.
DATE OF ISSUANCE , ~ ~~'
,~~~ ~ ~ ~~Q~ ~ ~ i7~ANLEY-S,;COOPER
A$SIST~I NT"STA+TE ~EC,,ISTRAR
LINCOLN, NEBRASKA HEALTH AND. HUMAN'S~R W~5 `
STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES °/
' CERTIFICATE OF DEATH - ~ '~~ O 7 t? ~ ~ ~:8.
1. DECEDENTS-NAME (First, Middle, Last, Suffix) 2 SEX v~. 0 3. DATE OF DEATH. (Mo Day,Yr.)
Robert Calvin Sneller Male.- ~. December 14; 2007 .
4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE-Last Birthday Sb. UNDER 1 YEAR 5c. UNDERI 4AY+~ ~g..,4}LTE OF BIRTH (Mo., Day, Yr.)
(Yrs.) MOS. DAYS HOURS MINS. ;,'. I. ~ /
Hastings, Nebraska 80 December 25, -1926
7. SOCIAL SECURITY NUMBER Ba. PLACE OF DEATH
o .460-24-0332 HOSPITAL: ^ Inpatient TO HER; ^ Nursing HamelLTC ^ Hospice Facility
U Bb. FACILITY-NAME (If not Instltutlon, glue street and number) ^ ERIOutpatlent ®Decedent's Home
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406 University
^ DoA ^otner(spaclry)
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8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
W
Z Hastings 68901 Adams
9a. RESIDENCESTATE 9b. COUNTY sc. CITY OR TOWN
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a
a Nebraska Adams Hastings
~ Od. STREET AND NUMBER 9e. APT. NO. 8<. ZIP CODE 8g. INSIDE.CITY LIMITS
406 University
68901 ®Yee ^ No
? 10a. MARITAL STATUS AT TIME OF DEATH ,~ Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wHa, give maiden name.
m ~~klarrled, but separated ^ Widowed ^ Divorced ^ Unknown -
w
a Marjorie Kurfman
0 11. FATHER'S-NAME (First, Middle, Wst, Suffix) 12. MOTHER'S-NAME (First, Meddle, Malden Surname) '
~ Flo d C Sneller Dr L die Sourezney
m 13. EVER IN U.S. ARMED FORCES? Give dales of service If Yes. 14a. INFORMANT•NAME 14b. RELATIONSHIP TO DECEDENT
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(Yes, No, or unk.) Yes 08/30/1944-07/09/1946
Marjorie Sneller
Wife
15. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE t6b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
^eurlal ^D°°'"°°
®Cromatlon ^Entombment Not Embalmed December 17, 2007
^Ramoval ^OlherlSPeclty) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY(fOWN STATE
Central Nebraska Cremation Gibbon Nebraska
17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 17b. 21p Code
Brand-Wilson Funeral Home, 505 N Bellevue, Hastings, Nebraska 68901
CAUSE OF DEATH (See instructions and examples)
_
1a. PART I. Enter the chain o/evenb . Elseases, injuries, or comPllcadone• that directly tausetl the death. DD NOT enter tannlnal srenls each as wMlac arrest, ~ ;APPROXIMATE INTERVAL
nsplralory arreel, or vemrlcular gbrlllallon without showing the etiology. DD NOT A6aREVIATE. Enter only one cauw °n a Ilns. Atltl atltlltlonal Ilnss If Mrassary.
IMMEDIATE CAUSE: ;onset to death
IMMEDIATE CAUSE (Final
Disease or condition resulting a) Heart Failure .Immediate
in death)
DUE TO, OR AS A CONSEQUENCE OF: ;onset to death
Sequentially Ilst conditions, If b)
any, leading to the cause listed
on Ilne a. DUE TO, OR AS A CONSEQUENCE OF: ~ onset to death
En[er the UNDERLYING CAUSE c)
(disease or InJury that Initiated
the events resulling in death) DUE TO, OR AS A CONSEQUENCE OF: ~ ~ onset to death
LAST
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18. PART II. OTHER SIGNIr-ICANTCDNDITIONS-Conditions contributing 1o the death but not resulting In the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
ORCORONER CONTACTED?
7E7 YES ^ NO
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LL 20. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
^ Nol pregnant within past year [~ Na"rural ^ Homicide ^ DrivedOperator ^ YES ~ NO
^ P
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ime c
eath ^ Accident ^ Pending Invesligatlon ^ Passenger
U ^ Not pregnant, but pregnant within 42 days of death ^ Sulclde
^ Could not be delermined
^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
TO COMPLETE CAUSE OF DEATH?
a ^ Not pregnant, but pregnant 43 days to 1 year before deaf ^ Other (Specify) ^ YES ~] NO
y ^ Unknown If pregnant within the past year
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OE 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, sUaet, factory, office building, cansWCUon site, etc. (Specify)
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O 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
I" ^ YES ^ NO
22f. LOCATION OF INJURY • STREET 8 NUMBER, APT. NO. CITYITOWN STATE ZIP CODE
23a. DATE OF DEATH (Mo., Day, Yr,) ~ Z 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
~~ a ~z 12/17/2007 12:30 m
": rn 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH v } O 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
az 12/14/2007 2:10 p
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23d. To the bast ~f my knowlodge, death occttrretl at the time, date and place
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24e. On the basis of examination andlor Investlgatlon, In my opinion death occurred
.
o ~ and due to the cause(s) stated. (Slgnamre and Title) a
at the time, date and place and due to the cause(s) stated. (Signature end Title)
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25. DID TOBACCO USE CONTRIBUTE TO THE UEATH7 26a. HAS ORGAN OR TISSUE DONATION BE ONSIDERED7 26b. WAS CONSENT GRANTED?
^ YES ^ NO ^ PROBABLY ~ UNKNOWN ^ YES NO Not Applicable If 28a Is NU ^ YES ^ NO
27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
Alyson Keiser Deputy Adams County Attorney; 0 BOX 71, Hastin s, NE 68902
28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
P pEC 2 ~ 2007
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