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HomeMy WebLinkAbout20081586N~J~1pAGE5 O~+ DOC TAX /~ pD CKR,,l!~~ FEES O(J pD _ V A CK ~ 9~ 76 } CHG ACCT RET FEES CASH RO.D CK~ L2FC'D i 12ETLIRN III~~IYIW~~~Wlll~llllnllln~ NT7M: v,~~51- t..~4-w N ~4-od RD COMP:~c RD /: ! R COMPARE: ,/q,n. CADAS: -~ AO / ADAMS COUNTY, NE FILED INST. NO.~~ Q_._ O ~ 15 ~ F) Date - - 08 Time ~,L~'l ~~ ~' REGISTER OF DEEDS RESERVED FOR REGISTER OF DEEDS RECORDING SPACE ADAMS COUNTY NE ~' ~- ~®~'k.~en -~`.~,~.~ CG ~~ `~ off' X1...,0 ~- T~~'e_.e. C.3~ ax~d~ ~-~- ~~ ~~ ~~e~ ~ ~i~o CZ~ , W~~ `.~`.~ c.~rd.~ ~ . tN ~ ~ On "~ hcR.' ~:~ d~ r©~~-~y ~. PAGE 1 OF o~ PAGES _. _ _ __ _....._..._...200815..86 WHEN THIS COPY CARRIES THE RAISED SEAL OF .NEBRASKA HEALTH ANL2 HUMAN SERVICES - - SYSTEM, Ff CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGlNAL-=RECDRD_O_N H_ LE-WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATJSTIGS:SE,C.TION~WH/CH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ - DATE OF ISSUANCE _ ~_"" "U _ J1 ~ ~ ~~~ANLEY S GROPER MAR ZOOS ±: A~SjSTANTSTAT'EREGISTLtAR LINCOLN, NEBRASKA HEALTHANB H{.(MAN SERI~CES~Y~7•EM -,~__ _ STATE OF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVJCB~h71V~13CE AND SUPPORT VffAL STATISTICS CERTIFICATE OF DEATH n ~ n '~ n i2 ~ 1. DECEDENT -NAME FIRST - MIDDLE UST Johann 2 SEX ~ ~. ' - 3. DATE OF DEATH /Month. Day. Year/ Paul T~~;T Friedrick Uden Male March 14, 2003. 4. CITY AND STATE OF BIRTH /M not in US.A.. name potmeyl Sa: AGE - LaSI Birthday UNDER 1 YEAR UNDER 1 DAV 6. DATE OF BIRTH /MOner. Day. Year/ Prosser Nebraska (Vrs.l 80 50. MOS.- DAYS ' Sc. HOURS' MINS. ' Ma 26 1922 7. SOCIAL SECURTIY NUMBER 6a. PLACE OF DEATH 505-48-9824 HOSPITAL: ^ Inpatient OTHER. '- ^ Nursing Home -- ~ Bb. FACILITY -Name (end insliiuyion, give sheet and number/ I ^ ER Outpatient ~ ^ Resitlence Mary Lanning Memorial Hospital ®~A ^ aherrsve~,ro, 8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CIYV LIMITS 6e. COUNTY OF DE;>TH Hastings Yeg ^X ND ^ Adams 9a. RESIDENCE -STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Code/ 9e. INSIDE CITY LIMITS Nebraska Adams Hastings 1911 W. 9th 68901 Yes ND ^ 10. RACE - (e.g., WNIe. Black. American kWian. 11. ANCESTRY le.g.. Italian. Mexican, German, elcl 12. ~ MARRIED ^ WIDOWED 13. NAME OF SPOUSE (l/ wile. give maiden name) elc.l lSpecityl White (Sped I ty German NEVER DlvoaceD M I Wilma R. Dankert 14a. USUAL OCCUPATION /Give AiMd work dyne during most o/workin tile ev n N a d 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION ISpecity only highest grade compleledl g , e re re l Farmer A riculture Elemenla; ro r Secondary l0-121 College It-4 or 5-I g l 1L 16. FATHER- NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME John F. Uden Anna Au ustin 18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT-NAME (Yes. no. or unk.l Ilt yes. give war and dales d aervicesl 4-14 - i 9 4 4 Yes WWII 6-h-194h Wilma Uden i YO. Irvr VnMAN I MAILING ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP, 1911 W. 9th, Hastings, Nebraska 68901 ~~~vncau a ~ ~ ~F ~ y T 21a. Mt7HOD OF DISPOSITION 21 b. DATE 21 c. CEMETERY OR CREMATORY NAME ~ / x ` ~V~ ®Burial ^Removal Mar. 20, 2003 Concordia Cemeter 22a. FUNERAL HOME -NAME ~ 21 d. CEMETERY OR CREMATORY LO CATION CITY OR TOWN STATE Livingston-Butler-Volland F.H. ^Cremalion ^DOnalwn Rural Juniata, Nebraska 22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP( 1225 N. Elm Ave., Hastin s, Nebraska 68901 23. IMMEDIATE CAUSE PART (ENTER ONLY ONE CAU PER LINE FOR lat. Ibl, AND Icp. I Interval between onset and deam n //ll I lal /' ~ V ~// ~7`/yf d/t~~~ ~ I I I DUE TO, OR AS A CONSEOU NCE ~ I Interval between onset antl deam I Ib) I DUE TO, OR AS A CONSEQUENCE OF: I I Interval between onset and tlealn I Ice I OTHER SIGNIFICANT CONDITIONS - CaMilions contributing to the deaM Due nd related PART PART III IF FEMALE. WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL II PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONE ? (Ages 10-541 Ves No Yes No Yes No 26a. 266. DATE OF INJURY /AID.. Day, Yr./ Z6c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED Accident ~ Untlalermined M Suicide ~ Pending 26e. INJURY AT WORK 261. PL11C~p~, INJURY - ~e.•t ho~~. larm, street. lacbry O ICe I Irlg eIC ~Padl! ~ r 26g. LOCATION ~ STREET OR R.F.D. NO. CITY OR TOWN STATE ^ Homicide Invasligation ^ ^ Yas ~ No , . } / • . ~~ 27a. DATE OF DEATH (Mo.. Uay. YcJ - 26a. DATE SIGNED (Mo.. Day. Yr.l 26b. TIME OF DEATH G ~ M ~= r J 27b. DATE SIGNED /MO. ay. Ycl 27c. TIME OF DEATH ~ ~ - 26c. PRONOUNCED DEAD IMO. Day, Yc! 26d. PRONOUNCED DEAD /HOUrT o g' G / ~ ~~~ M 27d. 7 e Aegl my know atlge. deaM accurr tl» ti dale lace a e to the ~ g ~ 26e. On the basis of examination and~onlnvestigalion, in my opinion tleath occurred at causelsl sealed. ° a Me time, date and place and due to the causelsl slated. ISi nature and Title ~ Si nature and Title ~ 29. DID TOBACCO USE CONTRIB E TO TH TH? .a HAS ORGAN OR TISSUE DONATION BEE N CONSIDERED? 30.b WAS CONSENT GRANTED? ^ VES NO UNKNOWN ~ y ^ YES I~ NO ^ YES ~NO -••~~••^••~~~••+~.~.~.•......vr~.cniiricn lrnron.inrv,r.vnvrvtna rnrJA:WN VM VVUNIY AIIVRNEYI lTygea Piinll ' John A. Beck, ER Rm MLMH, 715 N. St, Joseph, Hastings, Nebraska 68901 32a. REGISTRAR . .,.,~ ..._~ ~.. a~ BY REGISTRAR /AfD.. Day, yr/ MAR 2 0 2003