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Home My WebLink About20080103IVUMZAG~S ~L noc~x~,t7t TA crv: rz;~s ~(, o (L rUI(_p o crcn~5~`1 CIIG ACCT lI ]i1:1'P.CT,S: CASH ]i.O.U. C7C9 12L~C'A RliTUAZ1V~ r ~ C.`lQ. m~~X- . t''7 6 5 ~ ~ SS «i.~'r' ron NAsfrr~s Ne. &8ROr ADAMS COUNTY NE FILED INST. NO,._2,Q,0„8,41 ~ 3 Date~~T1me.~ . ~~"`"'~'db' REGISTER OF DEEDS ll- to - io NUM: /Yle uer.~u b RD COMP: ~~(~ /~~Oq COMPARE: iii CADAS: - AO ~/ IZLSEItVED FOR REGISTER OF DEEDS RECORDING.SPACE ADAMS COUNTY NE At the time of his death, he and his spouse, PATRICIA J. MEYER, were the ~ owners of record of the following real estate, to-wit: i Meyer Subdivision, Adams County, Nebraska; A tract of land in the Northeast Quarter of the Northeast Quarter (NE1/4NE1/4~ of Section Eleven (11), Township Six (6) North, Range Ten (10), West of the 6~ P.M., described as: Commencing at a point on the North Section. line which is 1034 feet West of the Northeast corner"thereof; running thence South at right angles to said North line a distance of 220.0 feet; thence West, parallel with said North line 110 feet; thence North 220.0 feet; thence West, parallel with said North line 110 feet; thence North 220 feet to said North Section line; and thence East on said North line 110 feet to the place of beginning; subject to county road on the north of said tract; and The Northeast Quarter (NE1/4) of Section Eleven (11), Township Six (li) North, Range Ten (10) West of the 6~h P.M., Adams County, Nebraska, containing 153.5 acres more or less; EXCEPT Meyer Subdivision, Adams County, Nebraska, and EXCEPT ~ tract of land in the Northeast Quarter of the Northeast Quarter (NE1/4NE1/4) of Section Eleven (11), Township Six (6) North, Range Ten (10), West of the 6~h P.M., described as: Commencing at a point on the North Section line which is 1034 feet West of the Northeast corner thereof; running thence South at right angles to said North line a distance of 220.0 feet; thence West, parallel with said North line 110 feet; thence North. 220.0 feet; thence West, parallel with said North line 110 feet; thence North 220 feet to said North Section line; and thence East on said North line 110 feet to the place of beginning; subject to county road on the north of said tract. ~~ ; PAGE 1 OI' a, PAGES STATE OF NEBRASKA ~QQpQiQ3 WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. / -s N'; DATE OF ISSUANCE h ,`~~~~,~TANL'E 5 'COOPER=. , AUG 0 S 2007 e . ASSISTANT ~TA7E REGISTRAR ': , LINCOLN, NEBRASKA HEALTH AIVD HUMAN SERVICE, ` ., - r - L ~ ~< s . STATE OFNEBRASKA-DEPARTMENTOF HEALTH AND HUMAN SERVICES FINANCE AND SUPPQAC, .. ~ 0 n ~ C /'`C~TI G1~'ATC AC IYG ATU .- ~ ff ~a /l ___-- _. --..... 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) '' _ 2, SEX ~ ~ ~ '~ f -T 1 3: DAYEOF DEATH (Mo., Day, Yr.) Leslie D. Me er Male - July 28, 2007 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGE-last Birthday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Hastings, Nebraska (vra.) 70 MOS. DAYS Houas MINS. ;April 12, 1937 7. SOCIAL SECURITY NUMBER fia. PLACE OF DEATH SOS-44-3345 HOSPITAL: ^ Inpatient OTHER ~I NursingHOmelLTC ^HospiceFacility 6b. FACILITY-NAME (II not ihstitutlon, glue street and number) Perkins Pavilion - - ^ ER/Outpalienf G Decedent's Home ^ 004 ^ Other(Specity) 6c. CITY OR TOWN OF DEATH (Include Zip Cade) 8d. COUNTY OF DEATH Hastings 68901 Adams 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN Nebraska Adams Hastings 9d. STREET ANDHOMBER 9e. APT. NO 9t. ZIP CODE 9g. INSIDE CITY LIMITS 1765 West Assumption Road 68901 OYES ~lNo 10a. MARITAL STATUS AT TIME OF DEATH Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Lasl, Suilix) II wife, give maiden name. ^ Married, but separated ^ Widowed ^ Divorced ^ Unknown Pat Kive t t 11. FATHER'S-NAME (First, Middle, Lasl, Suffix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Ernest Meyer Gertrude Stromer 13. EVER IN U.S. ARMED FORCES? Give dales of service it yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT (Yes, no, or unk.) No Pat Meyer ~ Wife 15. METHOD OF DISPOSITION 16a, ME TORE t6b. LICENSE N0. 16c. DATE (Mo., Day, Yr. ) Burial ^DOnation 1210 August 2, 2007 ^ Cremation ^ Entomhmenl 16 ERY, CREMAT RY THE LOCATION CITY /TOWN STATE ^Removal ^otner(speoiry) t. Paul's Lutheran Churchyard Cemetey West of Glenvil, Nebrask 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, Clty or Town, State) 1225 North Elm Avenue 17b. Zip Code ? Livin stop-Butler-Volland Funeral Home ~: 16. PART I. Enter the chain of events--diseases, lnjurles, orcomplications--that directly caused the death. DO NOT enter terminal events such es cardiac arrest, ~ APPROXIMATE INTERVAL I resplralory arrest, or venlrlcular Iibrillatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. I IMMEDIATE CAUSE: I onset to death I IMMEDIATE CAUSE (Final la) G~~~/' C Q ~5 I 1 1/LlFlw.l-~C"CA.-S . dlseaseorcondfllonresulting DUE TO, OR AS A CONSEQUENCE OF; I onset todaath In death) I Sequentially Ilst cond(tlons, I1 (b) I I _ any, leading tothe cause listed DUE TO, OR ASACONSEQUENCE OF: I onset to death on line a . A Enter the UNDERLYING CAUSE I (disease orln)urythat lnitlated (o) I the events reaulti I d th I ng n ea ) ~ DUE T0, OR AS A CONSEQUENCE OF: I onset io death IAST (~ I i6. PART II.OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER ' t CC7~Q 1.~~ l~I~DD-~l OR CORONER CONTACTED? ^ YES NO 20. IF FEMALE: 21 a. NNER OF DEATH 21 b. IF TRANSPORTATIONINJURY 21 c. WAS AN AUTOPSYP RFORMED? ^ Not pregnant within past year ~ Natural ^ Homicide ^ Driver/Operator ^ Pregnant al lime of death ^ Accident^ Pending Investigation ^Passen er g rX ^ YES ~q N0 ^ Nol pregnant, but pregnant within 42 days of death ^ Pedestrian ^ Suicide ^ Could not be determined pid. WERE AUTOPSY FINDINGS AVAILABLE TO ! ^ Not pregnant, but pregnan143 days to 1 year before death 4 ^ Other (Specify) COMPLETE CAUSE OFDEATH7 ^ Unknown it pregnant wllhin the past year ^ YES ^ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY m 22c. PLACE OFINJURY-At home, )arm, street, factory, ollice building, constructionsite, etc. (Specify) 22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED ^ YES ^ tJ0 221. LOCATION OF INJURY-STREET6NUMBER, APT.NO. CfTY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr.) = Y 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH a~ J 28 acaiZ ill ~y ~ _ } ~y0 23b. DATE SIGNED ( o., Day, .) 23c. TIME OF DEATH ~ _ ~ 24c. PRONOUNCED DEAD (MC., Dey, Yr.) 24d. TIME PRONOUNCED DEAD eaz u c ~ O U 6:40 a m E~~z m ~ ~ 23d. To the best knowledge, d al~ccu d t re me dal lace g Z ~ 24e. On the basis of examination andlor investigation, in my opinion death occurred at and duet Ih ause(s) slat ( na ¢ U the lime, dale and place and due to the cause(s) slated. (Signature and Title) F ~! U ` o 25. DID TOBACCO USE CONTRIBUTE TOTHE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERE07 26b. WAS CONSENT GRANTED? ^ YES ^ NO PROBABLY ^ UNKNOWN ^ YES NO Not Applicable if 26a is NO ^ YES NO 27.NAME, TITLE AND ADDR SS OF CERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNT ATTORNEY) (Type or Print) Davi 26a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) ,~. AUG 7 2007 ~il '~<~,' ;~5 aka