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HomeMy WebLinkAbout20080301NUM PGS DOC TAX CK#_,..._,_ FEES PD ~.SD CK#~ CHG ACCT#__,_,~ RET REES:_- t3ASH R.O.D. CK# RECD l'i~ ssi~ ~ J'.oi / ~ -~ f'~,-ke,- I,F 1;RN ' ~ _a'r'karr 11,fi~,riz 990/ Illllllllllllllllllllllnlllllll~llll~ :~~~ ~~ J. t~~MP '~~ S ~;AS ~ AO y ADAMS f OUDNTY, NE INST. N0. 3 0 ~. Date l-a `~ -n~_ Tlme ~r~~nl ~~~~ REGISTER OF DEEDS X0080301 WHEN THIS COPS' CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND_HUMAIItSERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD {31V FICEaM1!ITH . THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL: STATISTICS SECFION; YYH/CtL~lS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ,/ DATE OF ISSUANCE J0. ~~' O nn Q ~~~~~~~ANLEY S. COOP R = ~ ' ' `~ ~~ ~ ZU U ASSISTANT STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND HflIHAN SERVICESSY$TE~ STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEiZ1/ICES FQJANCEANIISCJPPORT VITAL STATISTICS r _ _-' CERTIFICATE OF DEATH` ---__- -NAM. FIRST MIDDLE LAST 2. SEX ---- 3. DATE OF DEATH ;MOnrh Day. Yzad _ Adam ~ CITY AND STATE OF BIRTH rlf nor in USA. name country! 6a. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DA E OF BIRTH !MOnM. Dav VearJ (Yrs.! 6b MOS I DAYS 6c. HOURS MINS I-[astines Nebraska 84 March 11 1916 7 SOCIAL SECURTIY NUMBER 6a PLACE OF DEATH ------ 50G-OS-5780 HOSPITAL: InpaLenl OTHER ^ Nursmy Hor~~e ___--- ^ __ Bb. FACILITY -Name /lI nnf rnslilufion, give sfree/ and number/ ^ ER Outpatient kr 1. Resdenoe 444 127 E. SOntll Street ^ DOA ^ Other iSPerrAr Bc (:Il ~..' (OWN OR LOCA f10N OE DEATH 60 INSIDE CITY LIMITS 6e. COUNTY OF DEATH Ilastmgs Yes © No ^ Adams ' .~ ^; SIDENCC 5TA14: 19h (.:iUNTY 9c. CITY. iUWN OH LGCAIION 90 STREET AND NUMBER /Includ gZrp Codel 9e INSIDE CITY LIMITS 14 ~ Nebraska Adams Hastin s 127 E. South Street, 68901 Yes ® fJn ^ 10. RACE ~ Ie.g.. Whlle. Blank. American Indian. t t. ANCESTRY leg.. Italian. Mexican. German, elcl 12.,x) MARRIED ^ WIDOWED 13 NAME OF SPOUSE )Il wr/z. give maidan Hama) elc.l ISuncilYl ISPecilyl -J ~ White German/Russian NEVER DlvoaceD MARRI ^ Mar B. Armstron __ g- I na. USUAL OCCUPATION rGlve kind or work done during moll u/ wnrkrn LAC evert it renr d 10b. KIND OF BUSINESS INDUSTRY t 5. EDUCATION ISpecRy only highest gratle compleletll q . z r Molder Foundry Elempr~ary or Secondary 10~ t 21 College ! 1 -~ ur i ~ i 11 16. FATHER -NAME FIRST MIDDLE LAST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Conrad Scheideman Elizabeth Alberts 16 WAS DECEASED IVER IN U.S ARMED FORCES? 19a INFORMANT -NAME !Yes no of unk I N III Yes give war and dales 01 services! L o _ - ___ Mary Scheideman 196. INFORMANT MAILING ADDRESS (STREET OR R.F p NQ.. CITY OR TOWN. STATE. ZIP( - _ 127 E. South Street, lastings, Nebraska G89M 20 BAL ER ~ SI ATURE 8 LICENSE NO/ : i'7 la. METHOD OF DISPOSITION 210. DATE 2tc. CEMETERY OR CREMAT ORV NAME ~ ~~ ~ 1 ,_ ,L- ' 05/08/2000 Parkview Cemetery __ 7 ~ Burial ~ Removal 2 F N A HOME -NAME `~, - 2ttl CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE rvingston-Butt r-Volland Funeral Home ^ Cremation ~ Donallon Hastings, NE 1225 N. EIm Ave. Hastings, NE, 68901 IMMtU1H I t l;I1lIJt PART ' ,a,~ I coronary accident DUE TO, OR AS A CONSEQUENCE OF Ibl DUE 70. OR AS A CONSEQUENCE OF: Icl Interval between onset and tlealn I immediate I Interval between tinsel and deallt I I I I Interval balween tinsel and dedllr I ~ OTHER SIGNIFICANT CONDITIONS ~ Conditions contributing to the death but not related PART PART III IF FEMALE. WA$ THERE A 2a AUTOPSY 26. WAS CASE REFERRED TO MEDICAL II PREGNANCY IN THE PAST 3 MONTHS EXAMINED OR CORCfJER~ _ ___ (Ages 10-6a1 Ves No ves No Yes No 11 2('a Na t u ra -L 26b Gri l - OF INJURY /MO.. Oay Yr.J 26c. HOUR OF INJURY 2Ed. DESCRIBE HOW INJURY OCCURRED ~~ ~ Acrirlenl ~ Unrlolerrn,nno I I I Su~c~de ~ Pnnd,ny 21 6e INJURY qT WORK 261 PLACE OF INJURY - At home. farm. M street. laclory 26g. LOCATION STREET OR R.F D. NU. CITY OR TOWN STATE ^ ^ oA¢e buJding. etc. /Specify/ ~ Homicide InveSnyauon Yes No _ 27a. DATE OF DEATH iMO. Day Yrl 26a. DATE SIGNED /Mo.. Dav. Vrl 28b TIME OF DEATH _ ' w 5-5-00 1:00 a M a ~ ' 27b DATE SIGNED IMO. Day. Vr.l 27c. TIME OF DEATH ~ i ~ } 26c. PRONOUNCED DEAD IMO.. Day. Yr./ 26d. PRONOUNCED DEAD /HOUrI oa - ~~ - ___ ___ M ~N ~ ~ 5-4-00 9:15 a M 27d I u the best of my knowletl e death occurred at th i l ° ~ ~ ,~ . g e t me, date antl p ace and tlue to the Cau5e15 staled. ~ '~ 26e. On the basis of examination an0or invesligal the lime tlale and lace and d e to Ih ca 5 ion, in my opi o e 11/~`occ rted~al } 4 s ~'Lr tl nl ~ ~ \ ~ ~ . p u u - l e r.I ` n ~ (Si nature and Title, - ISi nature and Title) - s' ~/~.L'N v~('~~ - ~ ~'L 29 DID TOBACCO USE CONTRIBUTE 70 THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONS E 7 GRANTED ^ YES ^ NO ® UNKNOWN ^ YES X^ NO ~ ^ YES ® NO 31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONERS PHYSICIAN OR COUNTY ATTORNEY( hype aPrinll Meredith Oakes Peterse D C n ut o. t ne PO B 32a REGISTRAR ~ _ _ fi~ _ ~~- 32b DATE FILED BV R IS RAR (MO.. Oay_Yr./ 2000 MAY Ql 7 c /~ - gr The West Half (W1/2) of Lots One (1), Two (2), Three (3) and Four (4) and the South Fifteen feet of the West Half of Lot Five (5) in Moxley's Addition to the City of Hastings, Adams County, Nebraska, according to the recorded plat thereof. (ENTER ONLY ONE CAUSE PER LINE FOR lat.