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ADAMS COUNTY, NE
FILED
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Date ~~ Time~~1
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REGISTER OF DEEDS
RESERVED FOR REGISTER OF DEEDS RECORDING SPACE
ADAMS COUNTY NE
Lots One (1) and Two (2), in Beale's Subdivision of'Block Twenty-one
(21), of St Joseph's Second Addition to the City of Hastings, Adams
County,, Nebraska, according to the recorded plat thereof; subject to
easements and restrictions of record.
PAGE 1 OF oZ PAGES
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STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
CERTIFICATE OF DEATH
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•.c, 1. DECEDENT'S-NAME (First, Mldtll e, Lest, Suffix
) 2. SEX 3, DATE OF DEATH Mo., Dey, Vr.)
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~ 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5e. AGE-Lest Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.)
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'~ (Yrs.) MOS. DAYS HOURS MINS.
,,(°'' Hall County, Nebraska 88 August 21, 1919
7. SOCIAL SECURITY NUMBER ea. PLACE OF DEATH
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- -
HOSPITAL: ^ Inpatient OStlE6: ~1 Nursing Home/LTC ^ Hospice Facility
:# Bb. FACILITY-NAME (Ii not Instltutlon, glue street end number) ^ ER/OUlpetient ^ Decetlanl's HOme
fi Perkins Pavilion
^ OCYf ^ Other (Specify)
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5 fie CITY OR TOWN OF DEATH (Include Zlp Code) Bd. COUNTY OF DEATH
' Hastin s 68901 Adams
~ 9a. RESIDENCE-STATE 96. COUNTY 9c. CITY OR TOW N
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1 Nebraska Adams H
~''; 9d. STREET AND NUMBER ee. APT: NO 9f. ZIP CODE 9g. INSIDE CITY LIMITS
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726 S uth St J
to YES ^ NO
10a. MARITAL STATUS AT TIME OF DEATH ^Marrled ^ Never Mauled 10b. NAME OF SPOUSE (FIrsL Middle, Last, Suffix) Ii wife, give maiden name.
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^Marrled, but separated C~Widowad ^ Divorced ^ Unknown
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~-u5rdai 1 i. FATHER'S-NAME (First, Mlddl e, Last, Sulflx) 12. MOTHER'S-NAME (First. Midtlle, Maiden Surname)
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ifi Harr Nietfeldt A
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13. EVER IN U. S. ARMED FORCES? Glve dates of service Ii yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
s1% (Vas, no, Drunk.) No David H r is
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15. METHOD OF DISPOSITION 16a.EMBA R-$IG TURE - 16b. LICENSE NO. 18c. DATE (MO., Day, Yr. )
`' ^BUrlal ^DOneuon _/ - ~~7 April 4, 2005
~';i f6j Cremation ^ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
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"~"~ ^Removal ^Other(Specify) BV Cremation Center Hastings Nebraska
~.~ 17e. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or TOwn, Slate) 1225 North Elm Avenue 17b. Zip Code
Livingston-Butler-Volla
nd Funeral Home Hastings, Nebraska
68901
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16. PART I. Enter the chain of events--diseases, Injuries, orcomplications--That directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
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respiratory arrest, or ventricular Ilbrllletlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional Ilnes If necessary. I
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IMMEDIATE CAUSE: I onset to death
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- IMMEDIATE CAUSE (Final (al .~ tl ~ +~
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'•~g disease or condition reeulgng DUE TO,OR ASA CONSEQUENCE OF: I onset to death
In death)
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Sequentially Ilat conditions, If
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any, leading to the cause Iiatetl
DUE TO, OR ASA ONS EOUENCE OF: I onset t ealh
on Ilne e.
Enter the UNDERLYING CAUSE I
(dlaeaee or Injury that Initleted (c) I
the events resulting In tleath) DUE TO, OR AS A CONSEOU ENCE OF: I onset to death
LASE
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(d) I
I 16. PART I1. OTH ER SIGNIFICANT CONDITIONS-Conditions contributing to the tleath but not resulting in Ina untlerlying cause given In PART I. 19. WAS MEDICAL EXAMINER
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OR CORONE~ NTACTED?
_ , ^ YES NO
,~ ; . 20. IF FEMALE: 21a.MANNER OF DEATH 21 b. IF TRANSPORTATIONINJURY 21c. WAS AN AUTOPSY PERFORMED?
~~ ` ~'.NOt pregnant wllhin past year ~Netural ^ Homicide ^ Driver/Operator
~ 4• ^ Pregnant el time of death ^ Accldent^ Pending Investigation ^ Passenger ^ YES O
y ^ Petlestrian
^ Nol pregnant, but pregnant within 42 days of death ^ Suicide ^ Could not be determined 21d. WERE AUTOPSY FINDINGS AVAILABLE TO
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f ^ Not re Went, but e ^ Other (Specify)
p g pr gnani 43 days lotyear before death COMPLETE CAUSE OF DEATH?
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.~~ ^ Unknown if pregnant wllhin tote pest year ^ VES ^ NO
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t" 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, farm, street. factory, oftlce building, construction site, etc. (Specify)
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INJURY AT WpRK7 22
DESCRIBE HOW INJURY O
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RED
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^ VES ^ NO
~$ 221. LOCATION OF INJURY -STREET & NUMBER, APT. NO. CITV/TOWN STATE ZIP CODE
s~! z 23a. DATE OF DEATH (Mo., Day, Yr.) _ } 24a. DATE SIGNED (MO., Day, Vr.) 24b. TIME OF DEATH
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_s J 23b. DATE IGNED Mo., Dey, Yr.) 23c.TIME OF DEATH J;r~ 24c.PRONOUNCED DEAD (MO., Day,Yr.)
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~ 24tl. TIMEPRONOUNCEDDEAD
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~ mo ~ 11.45 m N
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~ ~ 23d. Tot e b I of my knowledge, death occurred the Ilme, dale end place ~ ra°5 ~ O 24e. On the basis of examinetlon and/or investigaflon, In my opinion death occurretl at
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I `~,.~ c ~ to the ca se(s) stele gnalu tl Title •
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¢ ~ the time, dale entl place and due to the cause(s) staled. (Signature end Title)
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25. DID TOBA CO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 266. WAS CONSENT GRANTED?
' _~ VES ^ NO ^ PROBABLY ^ UNKNOWN O YES O Nat Applicable if 26a Is NO ^ VE NO
~.~~ 27. NA TITLE A D ADD ESS OF CER IFI R (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type ar Print)
20e. REGISTRAR'S SIGNATURE eb. DATE FILED BY REGISTRAR (Mo., Dey, Yr.)
HHS-61 11/03 (55061)
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