Loading...
HomeMy WebLinkAbout20080390?iif.4 PGS ' DOC TAX CK# FEES~~PD CK# CHG ~_- ~ ~ ACCT #~2L~.= RET FEES: CASH R.O.D. CK# Ri_~'DLY1E3Rk BECK RETURN ~~-~. LF\C~ 1 ~~~n.~Fs.._-E ~ $a o 1 I~IIVIIII~~IItl~~~nlll~ It!UM ,~q~rs ~ub oT ~P_lill,s ~iD. COMP x l~ o?=~Z7 COMPARE ~~ CADAS -' AO ~ ADAMS COUNTY NE FILED INST. N0. 3 ~ 0 Date t-~~-~ Time~~. ~~' v REGISTER OF DEEDS Lot One (1) except the West five feet (W5') thereof, Block Two (2), Kerr's Subdivision of Block Twelve (12) and Thirteen (13) of Lewis Subdivision of the Northeast Quarter (NE%) of the Southeast Quarter (SEl/,) of Section Eleven (11), Township Seven (7) North, Range Ten (10) West of the 6t'' P.M., in the City of Hastings, Adams County, Nebraska, according to the recorded plat thereof. ~~~ STATE OF NEBRASKA ~~ Q$ Q 3 9 O WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTHANQ H(/7l!lAN SERVICES SYSTEM, lT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORlGINAL~;€G~RD ON FILE WITH: THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VIAL ~T~F-TIS37CS ~E~~lON, ,WHICH JS THE LEGAL DEPOSITORY FOR VITAL RECORDS. -= __ - DATE OFlSSUANCE _ ~ ~ DEG 2 s 205 = -- TANLL~S=EOOPER A$S/S~ANT~TATE,"REGISTRAR LINCOLN, NEBRASKA _: HEAC'~HAND HUMAIEI SERVICES ' -; a 1 STATE OF NEBRASKA-DEPARTMENTOF HEALTH AND HUMAN SERVICES FIryA[TQ~~ND SUP_P(]RT CERTIFICATE OF DEATH -- -- " ~~~ ~ 1. DECEDENT'S-NAME (Flrsl, Middle, Last, Sulllx) 2 SEX -~ 3. DATE OF DEATH (M0, Day Yr.) ~'"-~--- Rcv e Male December 4 2005 ~~ 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday Sb. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) ;,~ ~ Frontier County near (Yrs.) MOS. DAYS HOURS MINS. 4`l~'°f .. Stockville, Nebraska 71 April 9, 1934 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH ''', 508-38-18$1 HOSPITAL: ~11npalienl OTHER: ONursing Home/LTG ^Hospice Facility 8b. FACILITKNAME (II not institution, give street and number) ~ ',, ~s {~ ;. ^ ER/Outpatient ^ Decedent's Home ~` Good Samaritan Hospital ');.,o-„ ' :.._ ___ ^ ~ ^ Other (Specify) „~{ '~ ~ Bc. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH ~ , Kearney 68847 Buffalo , - ~ r . LL', 9a.RESIDENCE-STATE 96.000NTY 9c. CITY OR TOWN Nebraska Adams Hastings ~ 9d. STREETAND NUMBER 9e. APT. NO 91. ZIP CODE - 9g. INSIDE CITY LIMITS i' ' 1727 West 6th Street 68901 X1 vas ^ No '~~,! ~ 10a. MARITAL STATUS AT TIME OF DEATH Mauled ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Lasl, Suflix) II wile, give maiden name. <'13 ,~~ . ^ Mauled, but separated ^ Widowed ^ Divorced ^ Unknown Joan ~I,enn.emann - c> I', hip 1 a 11. FATHER'S-NAME (First, Middle, Last, Sulf ix) 12. MOTHER'S-NAME (Flrsl, Middle; Maiden Surname) o < ~~ r" Guy Burton Elley Olive Mae Loshbaugh '' 13. EVER IN U.S. ARMED FORCES? Glve dates of service If yes. 14a. INFORMANT-NAME ' 14b. RELATIONSHIP TO DECEDENT (Vas, no, or unk.) No Joan Fl1.e. -~. ~.~: ~ ~. Wif e i ~ r;~ 15. METHOD OF DISPOSITION C~Burlal ^Donalion 16a. EMB M -SIG RE ~ - (/~/1 16b. LICENSE NO. ~~~ 1 fic. DATE (MO., Day, Yr.) December 9, 2005 '" I:s OCremallon ^Enlombmenl 16d. CEM RY, CREMATORY OR OTHER LOCATION CITY/TOWN STATE ' ^Removel ^Olher(Speclly) Parkview Cemetery Hastings Nebraska . 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Slreel, City or Town, Slate) 1225 North Elm Avenue 17b. Zip Code '~ : Livingston-Butler-Volland Funeral Home Hastings, Nebraska 68901 , ~, 15. PART I. Enter the chain of events--diseases, in)uries, orcomplications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL I respiratory arrest, or ventricular librlllation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines If necessary. I IMMEDIATE CAUSE: ~ I i onset to death I I ;yam ~ ~.~. ~~~ ~~ s ~~ I ~ IMMEDIATE CAUSE (Final (a) J ~~ I ~t l L~~ - -' "'~~i`- disease orcondltion resulting DUE TO, OR ASACONSEOUENCE OF: ~ I onset to death in death) J Sequentially Ilst condlllons, i1 (b) I I any, leedingto the cause Ilsled DUE T0, OR AS A CONSEQUENCE OF: I onset to death online a. jv~ Enter the UNDERLYING CAUSE I I,~.=%;~ (disease or ln)ury that lnltlated (c) I the events r ulti I d th es ng n ea ) DUE TO, OR ASACONSEQUENCE OF: I onset to death IASF 't . I (d) I 18. PART II.OTHER SIGNIFICANT CONDITIONS-Condillons contributing to the death but not resulling in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ~ ~ ^ YES 0 ~~ ; 20. IF FEMALE: 21a.MANNER OF DEATH 21 b. IFTRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? .., ~~ F ^ Not pregnant within past year ,,: ~ Natural ^ Homicide ^ Driver/Operator - , ¢¢ 'U~~I~' ~ ^ Pregnant al time o1 deelh ^ Accidenl^ Pending Investigation ^ Passenger ^ YES ~NO ~:~' ^ Nol pregnant, but pregnant within 42 days of death ^ Sulclde ^ Could not be delermined ^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE TO ^ Nol pregnant but pregnan143 days lol ear before death ^Other (Specify) ~ ~ ~ , y COMPLETE CAUSE OF DEATH? ~ ~ ; ^ Unknown II pregnant wllhin the past year ^ YES ^~NO t jj,. y, 22e. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c: PLACE OF INJURY-Al home, farm, street, factory, oflice building, construction site, etc. (Specify) m' --- m f°- 22d.INJURYATWORK? 22e. DESCRIBE HOW INJURY OCCURRED - ^ YES i_t: h10 ' 221. LOCATION OF INJURY- STREET & NUMBER, APT. N0. CITY/FOWN STATE ZIP CODE z 23a. DATE OF DEATH (Mo., Day, Yr.) z T 24a. DATE SIGNED (Mo., Day, Yr.) 24b.TIME OF DEATH a ~ December 4„ 2005 a ~¢ m ~_> 23b.DATESIGNED(Mo.,Day,Yr.) 23c.TIMEOFDEATH ~=k 24c.PRONOUNCEDDEAD(Mo.,Day,Yr.) 24d.TIMEPRONOUNCEDDEAD EaZ ~ December 15 2005 3:07 rn Ey~Z m 23d. To the best of my knowledge, death occurred al the Ilme, date end place ~ i ~ ~ 24e. On the basis of examinalion and/or invesllgation, In my opinion death occurred al end due lo se(s) slated. Sign ture ~ Tllle) ~ h i F z ~~ ` ~ F 0 p t e l me, date and place and due to the cause(s) stated. (Signature and Title) ~ U o 25. DIDTOBAC~'USE CONTRIBUTE TO THE DEATH? 26a.H GAN OR TISSUE DONATION BEEN CONSIDEREDI 2fib. WAS CONSENT GRANTED? _ ^ YES ~Cl NO ^ PROBABLY ^ UNKNOWN .~~E ~. NO Not Applicable if 26a is NO ^ YES ©~ N0 , 27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PH SICIAN OR COUNTY ATTORNEY) (Type or Print) Adeleke Bade'o M.D. 3219 Central Avenu Suite 103, Kearne Nebraska 68847 26a. REGISTRAR'S SIGNATURE ~ 2fib. DATE FILED BY REGISTRAR (MO., Day, Yr.) ~ ~a~c ~ ~ 200 ~-~a