HomeMy WebLinkAbout20081242NUM PGS
DOC TAX CK#
FEES /O.SP PD O.~p CK#a03Ip~
CHG ACCT #
RET FEES: CA$~,i ~ ~. j) .~
RECD ~~/u~c~a.
RETURN (1~/~tA JL~~kPr
--,~~ - ~ p
i~~~~III~~~Y~~~~
ADAMS COUNTY, NE
FILE~D(~~
INST. NO.,~t V ~L v ~. ~i 4 ~+
Date 3- as. °~ Time -~~C
S~~
u REGISTER OF DEEDS
NUM L awls S;..d //- 7 ~ ~/~F.~~, ~~i~
RD. COMP ,~ A~ ~'~~
COMPARE / ~
CADAS ~ AO `~
The Southeast Quarter of Block 5, in Lewis Subdivision of the Northeast
Quarter of the Southeast Quarter of Section 11, Township 7 North, Range
10 West of the 6th P.M. , in the City of Hastings, Adams County„Nebraska,
EXCEPT the West 75 feet thereof and excepting that part conveyed to the
City of Hastings for street purposes.
/ of ~.
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
DEPARTMENT OF HEALTH, IT CEKTIFIES IHE BELOW TO BE A TRUE,COPY),`:
OF AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT ;OF"HEALTH,;,
BUREAU OF VITAL STATISTICS, WHICH IS THE LEGAL DE$OSIT.ORY:FOR
VITAL RECORDS. ,{ `
• I,+ i '
~I
_ G'a~~~
DATE OF ISSUANCE ~C! /~.R/A.
i (1' ~ ' ? ; I : _% STANLEY S . COOPER, D.I~tEG~OF~'~ r/-'
LINCOLN, NEBRASKA BUREAU OF VITAL STAT`IS~TICS
STATE OF NEBRASKA - DEPARTMENT OF HEALTH
BUREAU OF VITAL STATISTICS
CERTIFICATE OF DEATH ?--
1. DECEDENT -NAME FIRST MIDDLE LAST 2. SE% 3. DATE OF DEATH (Month. Day. Year)
William S. Burgess Male February 20, 1990
d. CITY AND STATE OF BIRTH 111 not m U.SA., name country) 6a. AGE -Last Birthday N R t Y 6. DATE OF BIRTH /MOn(h
Day
Pearl
iYrs.i Sb. MOS. ! DAYS Sc. HOURS! MINS. .
.
North Lou Nebraska 56 ~ I November 6, 1933
7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
~
HOSPITAL'
Inpatient ^ ER~Outpalienl ^ DOA
507-36-0244 I OTHER: ^ Nursing Home ^ Residence ^ Olhar (SpacityJ
fib. FACILITY -Name /1/not insfilution, give street and number/ Bc. CITY, TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS fie. COUNTY OF DEATH
~ /Speciry Yes ar No/
Mar Lannin Memorial Hos ital Hastin s Yes Adams
9a. RESIDENCE -STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER /InUUding Zip Code/ 9e. INSIDE CI7V LIMITS
/Specify Yes br NoJ
Nebraska Adams Hastin s 1728 West 4th Yes
10. RACE - ie.g., White, Black, American Indian, 1 t. ANCESTRY le.g ,Mahan, Mex!car~.German, etc.l 12. MARRIED,NEVER MARRIED, 13. NAME OF SPOUSE /1! wi/e. grve maiden name)
etc.i (SpecilyJ (SpecityJ +
~ WIDOWED, DIVORCED (SpecityJ
White Irish Married Maril n Breckner
14a. USUAL OCCUPATION /Give kind of work done during most
> 14b. KING OF BUSINESS INDUSTRY - n
d working life, even i/ refired) ~ I /
. !~ lp ~ Elementary or Secondary 10-12J I College 11-< or 6*I
Car enter Y'"'r General Construction 12
16. ATHER -NAME FIRST MIDDLE LAST 17. MOTHER -MAIDEN NAME FIRST MIDDLE LAST
William S. Bur ass Thora McClarran
1fi. WAS DECEASED EVER IN U.S. ARMED FORCES? 19. INFORMANT • NAME -MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN, STATE, ZIP(
(Yes, no, or unk.) (Il yes, give war and dates of servienl Marilyn Burgess, Wife
1728 West 4th
No
-- ,
,
Hastin s NE 68901
20e. BURIAL, Cremation,Removal, 20b. DATE 20c. CEMETERY OR CREMATORY -NAME 20d. LOCATION CITY OR TOWN STATE
Donation
Burial Febr. 22 1990 Parkview Cemeter Hastin s Nebraska
21. EMBALMER - SI NATUR LICENSE NO.
~~2346 22 FUNERAL HOME -NAME AND ADDRESS (STREET OR R.F.D NO., CITY OR TOWN. STATE, ZIP(
Livin ston-Butler-Volland Funeral Home
1225 North Elm
,
23. IMMEDIATE CASE (ENTER ONLY ONE CAUSE PER LINE FOR la(, (bJ, AND Icl) 1 Interval between onset antl death
PART -
I ~/.. ~TrC. x I /
DUE TO, OR AS A CONSEQUENCE OF:
r _ I Interval between onset and death
I
^
2
v r \ 4t C ~.~L I ~.
S l~
\~ ~
C
'
'
~ ~
1
.
_~
~
Y-TSi
b
~
I ~
DUE TO, OR A A CONSEQUENCE OF. I Interval between onset and oeatn
I
I '
c
OTHER SIGNIFICANT CONDITIONS • Conditions contributing to tleath but not related
PART PART III IF FEMALE, WAS THERE A 20. AUTOPSY 26. WAS CASE REFERRED TO MEDICAL
II PREGNANCY IN THE PAST 3 MONTHS?
/Specify es or NoJ
E%AMINER OR CORONER
/Specity Yes or No) ~~
Yes ^ No O
~ -p
26a. ACCIDENT, SUICIDE, HOMICIDE, UNDET., 26b. DATE OF INJURY (Mo.,Day, Yr.J 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
OR PENDING INVESTIGATION (Specify/
26e. INJURY AT WORK 261. PLACE OF INJURY - Al home, farm, street, factory, 2 6g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
(Specify Yes or No/ o6ice building, etc. (Specity)
27a. DATE OF DEATH /MO.. Day. Yr.J 26a. DATE SIGNED /Mo., Day, YcJ 26b. TIME OF DEATH
") G
~ ~ -~ / ~
-
A,z <7( ~3~
27b. DATE SIGNED /MO
Day
Yr
) 27c
TIME OF D
EA
TH ~ ~ 2fic
PRONOUNCED DEAD
M
D
Y
.
.
, .
~ ~ .
/
O.,
ay,
r.J 2fid. PRONOUNCED DEAD (Hour)
gO
na ~/y
)
) -_- ~7~ b 'O [)
_
v
~ M Y
~ ~ o -
,0
j 27d
To the best of my knowledge
deatn occurred at the time
date d place and due to the o z o 26e
On th
D
Z .
,
,
ceuse(sl slated. ~ .-,
?
~ ~ a .
e
asis of ezammation arM-or investigation, in my oD~nion death occurred al
the time
date and
la
and d
to th
tat
d
l
~
~/ ~~
.~y~ ~
:/~\(
~ ~~ ~ ,
p
ce
ue
e cause
s( s
e
Si nature and Title ~ '.
~
! ~ Si nalwe and T!Ile
29a. DID TOBACCO USE CONTRIBUTE TO. THE DEATH?
~~~
~ 30a. HAS ORGANOR YISSUE DONATIONBEEN CONSIDEREDn -
~ 300. WAS CONSENT GRANTED?.. ~ ~ - -
~
~~~' fil-YES ~ NO
OUNKNOWN ~ ~ O-YES ~
~ ~- ~
^ YES - ,p-AIO-'~~
~. 3L.NAME AND ADDRESS-OF CERTIFIER •f PHYSICAN, CORONER'S PHYSICANOR COUNTY ATTORNEY) (Type or Print) : -
Dr. Davidl Howe, 2115 North'Kansas,'Hastings, Nebraska 68901
• 32a. REGISTRAR ~ 32b: DATE FILED BY REGISTRAR IMO.. Day. YcJ
M~~ ~ 4884
._ _ _____ _ _ Qrl:_,_
02 002. --