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HomeMy WebLinkAbout20081510NUM PGS DOC TAX CK# FEES D.,~PD~CK#~ CHG ACCT # RET FEES: CASH R.O.D. CK# RECD 8''JL~-~e~l~r~/~ (- RETURN ~/ ~ ~ lti'~ / ~f ~f c>s~ ~~r ll/E (v X3901 ~~BIA'IW6~dillnIIYIIIIINIIM1~ NUM ~~ lr~a ~ /~~~? RD. COMP Y .t~l~ f• y4' COMPARE ~ CADAS - AO `~ ADAMS COUNTY, NE FILED Date ~ -~ Time y_ REGISTER OF DEEDS Lot One Hundred Thirty-three (133) in Railroad Addition to the City of Hastings, Adams County, Nebraska, according to the recorded plat thereof. ~C~~- 20081510 STATE OF NEBRASKA WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT;,OF,~{E~1L,T,(I,,~ND ~ 0 0 815 i 0 'HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORI,G7NAL R~ ~!~ bN FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES,;;VI,~IA~tl2~~~KL~3"€i:~ ~ , t OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. , ~ ~ m te- ~~,~ ._ , ~, , DATE OF ISSUANCE '~a ~~" ~/~ CMG fa z3 fl ryry pp STAILcL~I" ~C~.Q~ER i7 ~ ~fiR ®?' ~U~li ASSIST'ANT` TOTE f~E'G,ISTRAI~~a e ~~ DEPARTMENT ~f'HEACTl-I AND`_~ "; LINCOLN, NEBRASKA HU1~1AlU,,~ER~VICES _, .• ~~r X1.1 T .a, c.7 y, , . . SiAiE OF ?IkBRA3[A- D~AN7l~df OF EBAL7H AND BIAi1A)1 f~.T11C8s POiANL$ A~ ~I f -~ L ` .}}• s~' i„r YfrM. srAnsna ~ ~,~ ~ ~... ~,~ L CERTQ~ICATE Of` DEA7IEI ?, r, `. „ ! i ~, t. DECEDENT • NAME flilST MIDOIE LABT t lEJI 3 pATE Oi:Bf/11N .Alst/'1 Qy..Ypy . ICe~ 10 1 a. GTY ANO STATE OF BIRTH Nna/Po USA.nMrcbV1/YI Sa AGE-l.aalBMteay U/I~III TEAR UOBIIDAY (DATE OFBIRM /1~LQIY YaW _-~ ' Guide Rock. Neblraska n~ I 62 sn tA05 av5 Sc NOLIAC AaNs Dea~ber 26 1938 ' 7. SOCNL SECURTIY NUMBER Y PIACF Of DE/ITtf °~.A< ©`°`" °"~•' ^ ",..~""'"" " 507-48-4984 - - .~ fACILITY.Nntn /1'•,e1A,.1A.eAyA.,...t.,AlAUraO.., ^ 61Dl~ra o a-°a j i'rA'"a'i`a7 ~1 `-".~ _ ~ DCN ^ Dh tSiw~tM: k CITY TOWN OR IOCAT1p1 DF OEATR Ao aySIDE CITY l1ABTS Ae COVITr C'f OFATN Hastings ~ ~ ~ yr Ne qa RESIDENCE•STATE 9b COUNTY qc CRY TOWN OR LOCATION Y STILT AAD MIi*1/'f .i~ciiy2!-CesN fa Ie/IDE bTY I:JMft Nebraska AdaICLS Hastings 500 S. (lhicacp 68901 ~ YBt ab 70 RAGE - N.q.. Whla. Blaca. AmariCAn atllan. 17. ANCESTRY leg. NaAan. IAaAKan. Gwman. alCr t 2 ryAM1ED ~ Nppll~ 17 k' 1E Of rOlll~ /t wf MaYiMln ywM ~II~~Nhite I>~~YI American ,E~, ~~ AO~p[13 H~ki[1 lN. VSUAL OCCUPATgN /Gnro A.redevrA ebne gaarg moer (tab KIND OF BUSINESS WOUSM d wpany Ab ewrl.Y leerstll PT1ttS naa. ro. a * ~ I In yes. gw+rar ano Gales d ssrviceal I ROBAanI1d Fritts l~ [~&~.I ~ Re.ro.ai LA7an 13, 2001 ~ Guide ROCK ^ Gamlaan ^ Doman 505 N. Bellevue Hastings NE 68901 _ 23 /MEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LME fOR ul lbl. ANO IGI -aovM Oabiaw AaM wa aean PMT lal DUE TO.OR AS A CONSEOVENCE anerW bel'Aetn vet an3 aean t ,~ ~-:~~, __ DUE 70.OR AS A CON OUENCE OF _ .. ~ aye..al srrw nu sn cvn ICI ~~'~/~'E""r' `^'\ OTHER SIGNFICANT Ci011DIT10N$ COAOY:nq b the Oe11~ bN rol relateE PALTi PART w i FEMALE WAS T/tEfE A 7a AUTOPSY 2S- WA;i CASE TEfEAREO TO AtFOKJa. a PREGNANCY q1 THE PAST 3 MONTR$' FANNER OR COROAtEA'r IA9a r0-`~1 Yes No Yes No Yas 116 26a 2Bb DATE OF M1A1RY /Ab OsY Yrl 2& /(GLIB OF NARY ZB0 DESCRIBE ROYy INJURY OCCUiMLED Accr1M ~ UnMNrmned M Sucga ~ PmWg 18e. INJURY AT WORT( 2111 PLACE OF MJURr / /y Ignq, (arm, slreeL lady, dk a n" S 2tiq LOCATpN STREET OR Rf.O. NO G7Y DR TOMM STATE NprsCga km549anD^ Yea ~ ND ^ . q pcN 27a. DATE OF DEANN IAb. Oav rr/ 2Ba DATE SIGNED /Ab Da1 vr/ 2Db TYE Of DEAN a< Januar 10 2001 a~~ M ~i 27b A E NEU lMb. OrY. Yrl 2%c T AE O OEATR k lac PRONOUNCED DEAD rATO D4'. » I 200 PRONOUFI(7:D DEAD A`itty~ ~ ' ' ~ ZZ ~' ~ ~ ~ ~ ~ 7 3 ~ M I y ~ 27e To ere bul ^W Y rLSN occurred Y aM sIM. Ctle aM dK! YIA b MI! ~ 7D! Ori fEe d saanr~rdr an0 W~ ac.an.A a1 °' ^~9~~ w TI' ep.w` tarrNSl yaled. • ~ ~ a aX Lrtie. dMs Yd Pbce and aw b h ta.ray aUled , I I ~~ ISgrWaa anA 7ak ~! W/ ~' and TM1 29 DIO TOBACCO USE CONTRIBUTE TO DEATN' a AN OR TISSUE DONATgN BEEN CONSIDEF!EG' _ 3D.0 WAS CONSENT GRANTEO~ rE5 ~ NO ~NANOWN ~ YES (~ NO ~ YES ® NO 31 NAME AND ADDRESS OF CERTIFIFA (PHYSICIAN. CORONER 5 PNYStCUW OR COUNTY ATTORNEY( i TR]e a PM~II Kevin K. Wycoff, M.D. 1021 W 14th St., Hastings, NE 6890 1 :4a. REGISTMR NII~C/{l //y 320 DATE. FILEDBt~JAN ~~LO~~ y ~~