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DOCTAX cx# I ADAMSO~UNTY, NE `
FEES SO pD .S.~O CK#_1- 20081002 INST. N0...,. ~~ ~ ~ ~ Q'~
CHG ACCT #
RETFEES: CASH R.O.D.CK# NUM T~~'~ ~/.~ oa~,~s Date 3L,~,~-Tim Z%f Q~-
RETURN.'/~~~ C~ilrfs~G~' RD. COMP ,X s~ ~,nt:f~, b~~sS''
COMPARE /~ ~ REGISTER OF DEEDS
~. ,,m ~
a ~~~s y` ~~~~~ CADAS AO
Lot Eight (8), Block Six (6), Imperial Village Fifth
Addition to the City of Hastings, Adams County,
Nebraska, according to the recorded plat thereof
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES .,
SYSTEM, !T CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD-ON FILE WITH ' ~ O O 8 ~ 0
THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISF~€S~E~T10N;39[HICHIS v V
THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ -_ - -
DATE OF ISSUANCE - ~~
r~~~d~~ NLEY-S G(IOPER
1 ~~ 2 ~~ 2 ~ ~ 4 ASSISTANT S'fi4Tf ~t~GISTRAR -
LINCOLN, NEBRASKA HEALTH AND I~UMAN SERVICES_SySTEM
STATE OF NEBRASKA- DEPARTMENT' OF HEALTH AND HUMAN SERVICES FIT'3~NCE ANFY SUPPORT
VITAL STATISTICS - , _ n /~
CERTIFICATE OF DEATH ~- - - ~ `~ ~ 1 ~ ~ `~'
1, DECEDENT -NAME FIRST - MIDDLE LAST 2. SEX - - - 3. DATE OF DEATH /Month. Day Year/
Harold Arthur Gartner Male October 13, 2004
4. CITY AND STATE OF BIRTH lIl not rn U.SA.. name country)
~ 5a. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAV 6. DATE OF BIRTH /Month. Day Year)
Holstein, .Nebraska (Yrs.l
81 Sb. MOS. i DAYS Sc. HOURS' MINS.
December 26, 1922
7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
507-18-4128 HOSPITAL: ® Inpatient OTHER: ^ Nursing HOme
Bb. FACILITY-Name /Nnol inslilu/ion, give-stree/and number) ^ ER Outpatient ^ Residence
Mary Lanning Memorial Hospital ^ oon ^ omer /spec,/vr
8c. CITY. TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS 8e. COUNTY OF DEATH
H3St7-ng8 Yes ~ No ^ Adams
9a. RESIDENCE -STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Code) 9e. INSIDE CITY LIMITS
Nebraska Adams Hostings 810 Sycamore 68901 Yes ® No ^
10. RACE - 1e.g., While, Black. American Indian. 11. ANCESTRY le.g.. Italian, Mexican. German, etc/ 12. ®MARRIED ^ WIDOWED 13. NAME OF SPOUSE /!/wile, give maiden name)
elc.1 ISpecilyl T,TM 1 t e
wll (Specify(
German NEVER DIVORCED
MARRIED
Milrae Albers
14a. USUAL OCCUPATION /Give kind o/work done during mos/
o/w
rki
til
it
i
d 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION (Speciy only highest grade completed)
o
ng
e, even
rel
re
l
Farmer
Agriculture Elementary or Secondary l0-12) College It-4 or 5~1
16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE - MAIDEN SURNAME
Henry H. Gartner Fannie Janssen
18. WAS DECEASED EVER IN U.S. ARMED FORCES?
1943
_03 19a. INFORMANT-NAME
(Yes. no. or unk.J
Yes -
pl yes. give war and dates of servic
~~
WWII 01-03-1946
Milrae Gartner
19b. INFORMANT MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
810 S camore, H stin s, Nebraska 68901
20. EMBALMERyS A7 E & t`7^~-p ~~ _,...,, .
r 1 0 21 a. METHOD OF DISPOSITION 21 b. DATE 21c. CEMETERY OR CREMATORV -NAME
°~ ~ Burial ^ Removal Oct . 16 2004 Parkview Cemeter
22a. FUNERAL HOME -NAME 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
Livingston-Butler-Volland F.H. ^aemafinn ^oonakon Hastin s Nebraska
22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP(
1225 N. Elm Ave., Hastin s, Nebraska 68901
23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR IaL IbJ. AND 1q1 I -Interval behveen onset and tlealh
PART
J~ I
A
1
~
I I
~
~ I
Ia1 I
DUE TO, OR AS A CONSEQUENCE OF~ I Interval between onset and death
I
Ib1 f ~.~ +~--t.ti1~ ~,tir'~A~1 ~(a I
_ I
DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and death
I
ICJ I
I
OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not related
PART PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
II PREGNANCY IN THE PAST 3 MONTHS? .EXAMINER OR CORONER?
/C
(Ages 10-541 Yes No Yes No ~ Yes No
26a. 26b. DATE OF INJURY /Mo.. Day. YiJ 2fic. HOUR OF INJURY 26d. DESCRIBE HOW IN,;JRY OCCURRED
Accident ~ Undetermined
M
Suicide ~ Pending 26e. INJURY AT WORK 261. PLACE OF INJURY - AI home, farm. slreel. factory
office building, etc. /SpecilyJ 26g. LOCATION STREET OR R.F.D. NO. CITV OR TOWN STATE
^
Homicide Invesligalion ^ ^
yes No
27a. DATE OF DEATH /MO.. Day. nl 26a. DATE SIGNED /Mo. Day. Yr1 28b. TIME OF DEATH
October 13, 2004 ~<w
U ~
M
o V
°' 27b. DATE SIGNED (MO.. Day. Yr.J 27c. TIME OF DEATH ~ > ~
aaa 28c. PRONOUNCED DEAD /MO.. Day, Yr.J 28d. PRONOUNCED DEAD /HOUrI
~~°
lc~ f(J 1~(
10:40 AM ~
~"~~
$'z~
M
a
'
F 27d. To the best of my know~Qge, death occurred at Jhe time. dale and place and 'e to the o 0 0
~ 28e On the basis of examination and~or investigation, in my opinion death occurred al
~ causelsl slated. 1 ) I tI ~ p ///~~~
~ ~
V
~
~~ ° ~ the lime, date and place and due to the causelsl staled.
I (Signature and Title/ -
V
'
\/~/ yYU~ ISi nature and Tllel -
29. ,DID T
BACCO
SE CONTR
IBU
E
70 TH
D ATFI 30.a HAS ORGAN OR TISSU
ONATION
N O
NSIDERED? 30.b WAS CONSENT
GR
D'
O
S
^
N
O
~
/-
~.
'~
1Ir
11
UNKNOWN E E
^
O ^
YES
- NO
31. NAME AND ADDRESS OF CERTIFIER (PHY
IC
S
I
A
N, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) /Type ar Print)
James W. Hervert M.D 211 N
32a. REGISTRAR /~/
1 I . J 32b. DATE FILED BV q(<Cy1~57~AR~/Mr~a~j5l~y p
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