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ADAMS COUNTY, NE
FILED
INST. NO ~ 4 ~
Date 3 .. r...~ Time,~„';(~„~. rrl
REGISTER OF DEEDS
RECORDERS ME'M0: ~~
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RESERVED FOR REGISTER OF DEEDS RECORDING SPACE
ADAMS COUNTY NE
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PAGE 1 OF a., PAGES
STATE OF NEBRASKA ~ ^ h
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHAND HUMAN SERVICES u u
SYSTEM, lT CERTIFIES THE BELOW TO BEA 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. //~ //,J/~~
DATE OF ISSUANCE 1 ~~ N' _' "~ ~
JAN 1 1 ?_008 TANLEYS. COOPER
ASSISTANT STATE REGISTRAR
LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES
STATE OFNEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERV ICES FINANCE AND SUPP
CERTIFICATE OF DEATH ~'rZ ~ ~ ~ ~~
~. ~ t. OtCEDENT'S-NAME (First, Mitltlle, Lasl, Sullix) 2. SEX 3. DATE OFOEATH (Ma, Day
~
Yr.)
,
: ,
Glenda Dee Brown Female December 21, 2007
5'
4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY DF BIRTH Sa
AGE-La51 Bi
lhtl
.
r
ey 5b. UNDER 1 YEAH 5c. UNDER i DAY fi. DATE OF BIRTN (MO., Day, Yf.)
I" ~' Gothenburg, Nebraska Iv'a.) 69 MOS. DAYS HOURS MINS.
1
March 30, 1938
i~ ~ ].SOCIAL SECURITY NUMBER
~ ' ~--42-2924 Be. PLACE OF DEATH
i
5
n ' f1S1SP1.TAL: ~11npetianl Q]LES ^Nursing HpmeA.TC ^Hoapke Feclllry
~ 80
F
¢ .
ACILITY-NAME (II not inslltullon, give street end number)
~'-!
~u? ' ^ ER/Oulpalienl ^ Oecetlenl's Home
: Mary Lanning Memorial Hos
ital
f'ia± p
;Y_.~
,Pa; ~ D04 ^ Other (Specily)
B
.: Jp
,~~Q O~~~ ,
c. CITY OR TOWN OF DEATH (Include Zlp Code)
Hasten 5 68901 60.000NTVOF DEATH
g
g=;x ' Adams
77LLV 9a. RESIDENCE STATE 9h.000NTY &. CITY OR TOWN
~;z;,~=
:;~~ Nebraska
; Adams
Hastings
T(tll 9d. STREET AND NUMBEfl 99
APT
NO
r.,
514 S Garfield St .
. 91. ZIP CODE
9g. INSIDE CITY LIMITS
+~I'~
10a
MARITAL STATUS AT TIME 68901 7D vas ^ No
~ .
OF DEATH g} Married ~ Never Married 100. NAME OF SPOUSE (First, Middle, Lesl, Sullix) II wile, give maiden name.
,y'.'
~' ^ Marrietl, but seperaletl ~ Widowed Q Divorced ~ Unknown
Daniel Brown
~~
~
7m
; 11. FATHER'S-NAME (First, Mitltlle, Lesl, Sullix) 12. MOTHEfl'S-NAME (First, Mitltlle, Meitlen Surnsme)
Simon Dircksen Lena Collins
/3. EVER IN U.9. ARMED FORCES? Give dales OI service it yes. IIa. INFORMANT-NAME
~ }
(Yes, no, or unk) NO
Daniel BroT~-n 14b. RELATIONSHIP TO DECEDENT
Husband
j~'...`
{
`'
~ 15. METHOD OF DISPOSITION 16e.EMBALMER-SIGNATURE
160. LICENSENO.
16c. DATE IMO., Day, Yr.)
E
;? oBprial ^Ddnafien Not Embalmed
r~cember 23, 2007
$I Cremation ^Emombmenl t6d.CEMETERY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE
~
' oRempyal ^otner(sPe~lly) Central Nebraska Cremation Service Gibbon, Nebraska
'V
,
~ 77e. FUNERAL HOME NAME AND MAILING ADDRESS I91rea1, CilyorTawn, Stale)
1 17b. Zip Code
D~^htt FLUnsal Hare and CreTation S,xvice, 1247 N Burlinatai Ave., Hastings, NE 68901
wta" .} fin.' ~"IA7~ .. .: • „
18. PART I. Enter the Maln of R-tl9aesea Inlurles, or compl callona-that tlueclly caused the death. DO NOT,enler lermmal events sash es car0lac srresl, APPgOXIMATE INTERVAL
- respiratory srresl, or renlricular librillalion without showin Iha etiolo .DO NOT ABBREVIATE. Enlar Onl ~
p gY yone cause on aline. Atltl atltlllional lines it necessary
IMMEDIATE CAUSE: I onset to death
i`~'raf
~j '~~y~ I
II~~ 11
IMMEOIATECAUSE (Final 1al ~--Q-`h UQ ~W+~'~ I
dl
aease OrcondilionrdulOng DUE TO,OR A9 ACONSR UENCE OF'
I dnsel to death
Intlealh)
i0. ~; {_.. Sequentially lislcsndiliongB (01 ~
any, leatling to lha cause listed I
DUE T
O, OR ASACONSEOUENCE OF: 1 onset to deem
on line a.
- Enlerlhe UNDERLYING CAUSE I
(Olsease er fn)urythal lnillaled (c) I
-
~
'(
~ N
e e
venla reaullin
lntleelh)
,
..~
,
I p
y
g
DUE TO, OR ASA CONSEQUENCE OF: ~ I Ansel to death
I
(d) I
16. PART II.OTHER SIGNIFICANT CONDITIONS-COntlilians conbibuling to 1ha tlaam 0ul not reaulling In me untlarlying cause given in PART I. 19. WAS MEDICAL EXAMINER
Ofl CORONER CONTACTED?
~ ~ YES NO
¢
.!
! 2s0~. IF FEMALE: 21a A1
NER OFDEATH
/µ 210.IFTRANSPORTATION INJURY 21c. WAS ANAUTOPSY flFORME07
iI,F ~, ,
SCI NOl pregnant within past year q
,,
y~velurel ~HOmicitla Driver/Operator
~.~w,
'U
~r
Pregnant el lime of tleelh I
^ACCidenl^Pending lnvesligalion I~passe
rlger ^ YE9 "NO
N
y~1 ONOl prepnanl. but prepnenlwilhin 42 days of tlealh
09uicltle OCgulO not be tlelerminetl ^Petleslrian 21d. WEREAUTOPSY FINDINGS AVAILABLE TO
4
"e Y; ^ Nol prepnanl, Md pmgnan143 days lot yser 0elore tleam ^Other (SDeCily)
S
S
C~E~I~
^ UnNnownil pregnant wilhln the pass year COMPLETE CAUSE OF OEATHY
^ YES ^ NO
U.
}'m 22a. DATE OF INJURY (Ma., Day. YrJ 220. TIME OF INJURY 22c. PLACE OF INJURYAI home, term, slr6el, leclory, ollice Ouiltlinp, consVUClIOn site, eta (Specily)
22tl.INJURV AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
^ YES ^ NO
221.LOCATION OF INJURY-STREETSNUMBER, APT NO. CRY/fOWN STATE ZIP CODE
23a. DATE OF DEATH (MO., Day, Yr.) i r 24e. DATE SIGNED (MO., Day, Yr.) 24b.TIME OF DEATH
a~ December 21, 2007 ~~~ m
w = J 23b. DATE SIGNED o., Oar, Vr. 23c.TIME OF DEATH
iZr m k 24c. PRONOUNCED DEAD (MO., Day,Yr.) 24d. TIME PRONOUNCED DEAD
E mo
I 2-1.I 3:38 a m a~
o-
w m
0
230. TOIhebesl of my kn IOge,tlealhoccurrad al lhellme,tleleentlplece
' m
~o
w~
24e Onlhe bas sot examnalanand/or nvesl gallon, inmyopmian Oealhoccurre0 al
,. 1= < an00ue to the ca s slale0. (Sg al r antl T
le) • B o
0
O Ihelma. dale end lace and due to the causes elated. Si
P () ( gnalura antl Title)
~
U„l, i'Ji F
¢
~ s
25. DIO TOBACCO USE CONT IBUTETOTHE DEATHI 28a.HAS ORGAN OR TISSUE DONATION BEEN CONSIOEflED7 26b. WAS CONSENT GRANTED?
^ YES ^ NO ^ PROBABLY NKNOWN ^ YES 0 Nol Applicable i126a is N0 ^ YES NO
.~ 27.NAME,TJILF nNDN10pE~SOF 6E~'IFlEftlPilV91CIAN,CORONER'S PHYSICIAN OR COUNT ATTORNEY)(Type or Print)
::JJ BBVla L LLl 1`1-L
2115 N Kansas Ave. Hastin s NE 68901
28a.REGISTRAR'S SIGNATURE 280. DATE FILED BY REGISTRAR (MO.. Oay,.Vr.)
~ ~ ~1 • JAN 1 7 2008
~~ r2