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Please index against the following real estate:
ADAMS COUNTY, NE
FILED
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Date 3 ~a6-n~'Time ~ =~~ ~1
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REGISTER OF DEEDS
The Southeast Quarter (SE'/4) of Section Twenty-four (24), in Township Seven (7)
North, of Range Twelve (12), West of the 6`h P.M., in Adams County, Nebraska; and,
The West Half (W%) of Section Nineteen (19), in Township Seven (7) North, of Range
Eleven (11), West of the 6`h P.M., in Adams County, Nebraska, except the following:
Commencing at a point 945.6 feet West and 53.57 feet South of the Northeast corner of
the Northwest Quarter (NW%4) of Section Nineteen (19), in Township Seven (7) North,
of Range Eleven (11), West of the 6th P.M.; thence South at a right angle to the South
line of Highway No. 6, a distance of 215.0 feet; thence West parallel to the North line of
said section a distance of 106 feet; thence North 215.6 feet to a point on the South line
of said Highway No. 6, 106 feet West of the point of commencement; thence East on
the said South line of Highway, 106 feet to the point of commencement.
l~ 2
STATE OF NEBRASKA '~ ~ ~ ~ ~ ~ Q'''`
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
SYSTEM, lT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORb ON`FILE WITH,
THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS' S~~T,~(SI~, ,,[~VHIC~-1lS
THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~ ' ~ A, ° •
,~ .'~
DATE OF ISSUANCE `:
,'r : TANL~Y S:' COOPEfT
O3/") 3/2008 ASSISTANT'SxA?E REGISTRAlj I a
LINCOLN, NEBRASKA HEALTH AND'-HUMAN SERVICES;,,: '"
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Amended STATE OF NEBRASKA -DEPARTMENT OF HEALTH AND HUMAN SERtVIGES , / :~ '• 08 QO126
CERTIFICATE OF DEATH ~~ ''~ ' < ' ~'' -~ • ~'
1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX ' ~ `
~ „•1 ~~ 3, pATE 0F, DEATH'(Mo., Day, Yr.)
) „ .,, .
~
Darbue Emma Einspahr Female°'~'•^ •~~. , 2008
"'February 11
~
4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE -Last Birthday b. UNDER 1 YEAR Sc. UNDER-1 DAY ~ DATE OF BIRTH (Mo., Day, Yr.)
-'6:
(Yrs.) MOS. DAYS HOURS MINS.
Holyoke, Colorado 85 Jahuary 16, 1923
7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
507-64-9777 HOSPITAL ®Inpatient OTHER ^ Nursing Home/LTC ^ Hospice Facility
~
Bb. FACILITY-NAME (If not Institution, glue street and number) ^ Decedent's Home
^ ER/Outpatient ~
O
I-
Mary Lanning Memorial Hospital ^ DOA ^ Other (Specify)
~ 8c. CITY OR TOWN OF DEATH (Include Zip Code) 8d. COUNTY OF DEATH
o Hastings 68901 Adams
Q 8a. RESIDENCE-STATE 9b. COUNTY 9c. CITY ORTOWN -
w Nebraska Adams Hastings
~ 9d. STREET AND NUMBER 9e. APT. N0. 9f. ZIP CODE 9g. INSIDE CITY LIMITS
~' 233 N. Hastings Avenue 314 68901 ®Yes ^ No
~ MARITAL STATUS AT TIME OF DEATH ^ Married ^ Never Married
10a 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
v .
tb
!'.
^ Married, but separated ®Widowed ^ Divorced ^ Unknown
2 11. FATHER'S-NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
d
d
Allen Roscoe Karr
Emma Alvina Hahlweg
~ 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
$ (Yes, No, or unk.) No Michelle Giddens Granddaughter
Q 75. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
F ®Burlal ^ Donation Henry Opbroek 1147 February 16, 2008
^ Cremation ^ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
^ Removal ^ Other (Specify)
Zion Wanda Lutheran Cemetery Juniata Nebraska
17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
Jackson-Wilson Funeral Home, 209 N. Smith Ave, PO Box G, Kenesaw, Nebraska 68956
CAUSE OF DEATH See instructions and exam les
18. PAR71. Enter theghain of eventg_-dlaeases, Injuries, or complications-that directly caused the death. DO NOT enter terminal events such as cartllac arrea:, ; APPROXIMATE;NTER'JAL
respiratory arrest, or ventricular fibrillation without showing [he etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Atltl atlditional Ilnes if necessary.
IMMEDIATE CAUSE: ~ onset to death
IMMEDIATE CAUSE (Final a) Cerebral Vascular Accident i 1 Week
disease or condltlon resulting
in death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
Sequentially list conditions, if b)
any, leading to the cauae Ilsted
on line a. DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
Enter the UNDERLYING CAUSE C)
(disease or injury that lnblaled
the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
LAST d)
18. PART II. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
OR CORONER CONTACTED?
^YES ®NO
~
W
LL 20. IF FEMALE: 21a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
H ^ Not pregnant within past year ~ ®Natural ^ Homicitla ^ Drtver/Operator
^YES ® NO
~
W ^ Pregnant at time or death A
Investi
ation
id
nt ^ Pentlin ^ Passenger
U
^ Not pregnant but pregnant within 42 days of death ^
g
cc
e
g
Suicide Could not be determinetl
^ ^
^ Pedestrian
21d. WERE AUTOPSY FINDINGS AVAILABLE
O COMPLETE CAUSE OF DEATHS
d ^ Not pregnant, but pregnant 43 days to 1 year before death ^ Other (Specify) T
~« ^ Unknown If pregnant within the past year YES NO
d
E
a
u 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•At home, farm, street, Tactory, office building, construction site, etc. (Specify)
a 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
0
F-
^YES ^ NO
22f. LOCATION OF INJURY - STREET R NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
23a. DATE OF DEATH (Mo., Day, Yr.) Z } 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
a a February 11, 2008 a ,a-,
O U
, 23b. DATE SIGNED (Mo., Day, Yr.)
~
23c. TIME OF DEATH
m = k Y
24c. PRONOUNCED DEAD (Mo., Day, Yr.)
24d. TIME PRONOUNCED DEAD
}
E a Z Februa 14, 2008 05:25 PM E N a=
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d
23d. To the bast of my knowledge, death occurred al the time, date and place w z at
24e. On the basis of examination antl/or Investigation, In my opinion tleath occurre
a c and due to the cause(s) stated. (Signature and Title) ~ 0 p the time, date and place and due to the cause(s) stated. (Signature antl Title)
a Justin Wenburg, MD K U
~ g o
25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
^ YES ^ NO ^ PROBABLY ® UNKNOWN ®YES ^ NO Not Applicable if 26a Is NO ^YES ®NO
27. NAME, TITLE AND ADDRE S OF CERTIFIER (PHYSICIAN, ORONER'S PHY ICIAN OR COUNTY ATTORNEY) (Type or Print)
Justin Wenburg, MD, 2115 N Kansas Avenue, Hastings, Nebraska, 68901
26a. REGISTRAR'S SIGNATURE ~ 26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
- February 19, 2008
Amended
3!13!2008 Amended 9c,d,e,f
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