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ADAMS COUNTY, NE
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REGISTER OF DEEDS
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RESERVED FOR REGISTER OF DEEDS RECORDING SPACE
ADAMS COUNTY NE
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- STATE OF NEBRASKA 12,r U 0 813 3 9
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH ANb H!/MAN_:SERVICES
SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RED77RD ~iv=1=i~€WITH
THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC-~S~CT')ON,: WNICH-_!S
THE LEGAL DEPOSITORY FOR VITAL RECORDS. - _ _
DATE OF ISSUANCE ~ ~~ _ _
n q 1 `~~~~~T_ANLEY'S: COOPER
JAN ~ ® (_~~7 ASSISTANT STATE REGISTRAR-,
LINCOLN, NEBRASKA HEALTH AND. HUMAN SERVICES''
STATE OFNEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPOrR'T ) /~~ ~`,
reo~rtrtr+nTG f1G IIFATH li ly/ /~' ~f~~ l'•J~
1. DECEDENT'S-NAME (First, Middle, Lasl, Suflik) 2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
Robert L. Uhrmacher Male
~ Januar 12 2007
CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
4 Sa. AGE-Last Birthday 5b. UNDER 1 VEAR Sc. UNDER 1 DAY 6. DATE OF 81RTH (Mo., Day, Yr.)
. (Yrs.)
83 MOS. DAYS HOURS MINS. March 21 1923
~
Adams County, Nebraska
n ?.SOCIAL SECURITY NUMBER 6a. PLACE OF DEATH -
'tl~; 505-16-2793 y.Q$P TA CA Inpatient OTHER: ^ Nursing Home/LTC ^Hospice Facility
~~ ~~°
¢; Bb. FACILITY-NAME (I1 not Inslilution, give slreel and number) ^ ER/Oulpalienl ^ Decedent's Home
'~ Mary Lanning Memorial Hospital -"
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,~ ^ DLN ^ Other (Specify)
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Bo. CITY OR TOWN OF DEATH (Include Zlp Code) 6d. COUNTY OF DEATH
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~ Hastings 68901 Adams
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~~. 9a. RESIDENCESTATE 9b. COUNTY 9c. CITY OR TOWN
f Nebraska Adams Hastings
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9d. STREET AND NUMBER 9e. APT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
t 'C' Street
322 W 68901 K1 YES ^ NO
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MARITAL STATUS AT TIME OF DEATH ^ Married ~ Never Married
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iDb. NAME OF SPOUSE (First, Middle, Lasl, Suflix) II wile, give maiden name.
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^ Married, but separated ^ Widowed ^ Divorced ^ Unknown
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ti 11. FATHER'S-NAME (Flrsl, - Middle, last, Suflix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
`o William Uhrmacher Amanda Kothe
,,;~~A;: 13. EVER IN U.S. ARMED FORC ? Give d f ser I I y s.
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~5° 14a.INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
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(Yes, no, or vnkJ yes J
, 12. 46
F h Niece
~~~. _' 15. METHOD OF DISPOSITION _
16a. EMBALM -SIGNAT E 16b. LICENSE N0. 16c. DATE (Mo., Day, Yr. )
lABnrl21 ^DOnalon ~
~ 1279 Januar 16 2007
^Cremation ^Enlombmenl _
OR OTHER LOC ON CITY/TOWN STATE
16d. CEMETERY,CREMATOR
"'° ^Removal ^Olher(Specily) Parkview Cemetery Hastings Nebraska
FUNERAL HOME NAME AND MAILING ADDRESS (slreel, Cily or Town, Slate) 1225 North Elm Avenue t7b. Zip Code
17a
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Livingston-Butler-Volland Funeral Horne Hastings, Nebraska 68901
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18. PART I. Enter the chain of events--diseases, in)uries, or compllcatlons--that directly caused the death. DO NOT anler terminal events such as cardiac arrest, APPROXIMATE INTERVAL
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respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines it necessary. I
I onset to death
USE:
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IMMEDIATE
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IMMEDIATE CAUSE (Final (a) /~}j-. ~ ~...r
disease orcondition resulting DUE TO, OR ASACONSEOUENCE OF: I onset to death
In death) I
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Sequentially list condlllons, II ro) I
any, leading to the cause llsled DUE TO, OR ASACONSEQUENCE OF: I onset to death
on Tine a. I
Enter the UNDERLYING CAUSE I
(disease or ln)ury that lnitlated (c) I
the events resulting In death) DUE T0, OR AS A CONSEgUENCE OF: I onset to death
LAST ~ I
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.-" 1 B. PART IL OTHER SIGNIFICANT CONDITIONS-condlllons conlribuling to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
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OR CORONER CONTACTED?
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^ YES ~NO
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8 , 20. IF FEMALE: 21a. MANNER OF DEATH 21b.IF TRANSPORTATIONINJURY 21c. WAS AN AUTOPSY PERFORMED?
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^ Not pregnant within past year J~Nalural ^ Homicide ^ Driver/Operator •~~~---~yy~
^ YES yp 1~lD
^
^ Accidenl^ Pendin Invesli aflon
9 g ^ Passenger -' \~
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~.d~. Pregnant al lime of death
; ^ Nol pregnant, but pregnant within 42 days of death
^ Suicide ^ Could not be determined ^Pedestrian 21d.WERE AUTOPSY FINDINGS AVAILABLE TO
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! ^ Nol pregnant, but pregnant 43 days Io i year belore death ^Other (Specify)
- COMPLETE CAUSE OF DE/SH7
'. a, '~ ^ Unknown if pregnant within the past year ^ YES ~0
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22a. DATE OF INJURY (Mo., Day, Yr.)
22b. TIME OF INJURY
22c. PLACE OF INJURY-AI home, larm, slreel, laclory, oflice building, conslrucllon site, etc. (Specify)
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~ 22d.INJURY AT WORK?
~ 22e. DESCRIBE HOW INJURY OCCURRED
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22f. LOCATION OFINJURY-STREET&NUMBER, APT.NO. CITY/rOWN STATE ZIP CODE
23a. DATE OF UEATH (Mo., Day, Yr.) Z y 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
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aU Januar 12 2007 a~z m
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23b. DATE SIGNED (Mo., Day, YrJ 23c.TIME OF DEATH u = ~ 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
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mo 3:23 A m a a'' m
Januar 16, 2006 0¢~0
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~ ° 23d. To the best of my knowledge, death occurred al the time, date and place w ~ 24e. On the basis of examinallon and/or invesligalion, in my opinion death occurred al
dale and place and due to the cause(s)!stated. (Signature end Title)
'~ the time
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and due to the cause(s) staled. (Signature and Title) • o ¢ U
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25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
Y
i NO
~ ^ YE~~JO ^ PROBABLY ^ UNKNOWN ^ YES "~.NO Not Applicable if 26a is NO ^ YES
27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
r'" Michael G. Skoch M.D. 223 East"14th-..Street Has in s Nebr sk 68901
28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
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4l W1~~,~e (1__ Z 2001
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