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ADAMS C0~ NTi', NE
INST. N0.~6 4 3
Date .20 O~Time ~~ -s„t°,~1
~~~~
REGISTER OF DEEDS
Lot Fourteen (14), Block Three (3), Gedney's Addition to
the City of .Hastings, Adams County, Nebraska, according
to the recorded plat thereof.
Rev. 1 7/57 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPORT
VTl'AL STATISTICS
CERTIFICATE OF DEATH
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1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH /Month. Day. Vear1
Doris Lola Galloway Female July 26, 2001
4. CITY AND STATE OF BIRTH (//nofn US.A.. name counhyJ Sa. AGE -Last Birthday UNDER 1 YEAR UNDER t DAY 6. DATE OF 81RTH (MOWN. Day. Year/
Hastings Nebraska IYrs.I
84 5b. MOS. DAYS
I 5c. HOURS ~ MINS.
~
June O5, 1917
7. SOCIAL SECURTIV NUMBER Ba. PLACE OF DEATH
505-16-1414 HOSPITAL: ® Inpatient OTHER: ^ Nursing Home
Bb. FACILITY -Name /!l not inslifufion, give sl~eel and number) ^ ER-Outpatient ^ Residence
Mary Lanning Memorial Hospital ^ DOA ^ Other /Spenly7
Bc. CITY. TOWN OR LOCATION OF DEATH 6d. INSIDE CITY LIMITS Be. COUNTY OF DEATH
Hastings Y
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^ ''Adams
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9a. RESIDENCE • STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Code/ 9e. INSIDE CITY LIMITS
Nebraska Adams Hastings 707 East 3rd St., 68901 Yas ® No ^
10. RACE - ie.g., White. Black. American Indian, 11. ANCESTRY le.g.. Italian, Mexican, German, etch 12. ~ MARFIED ^ WIDOWED 13. NAME OFSPOUSE /ll wile. give maiden name/
I
~~ipPte I It~erman
NEVER DIVORCED
MA I
Ral h Gallowa
74a. USUAL OCCUPATION /Give kind of work done dwing most 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION Specify only highest gratle completedi
orking fi ve it retired)
time `~a~Cer
Own Home
Elem;n~ry or Secondary 10-721 College II-4 or 5~1
11
16. FATHER -NAME FIRST MIDDLE LAST 77. MOTHER FIRST
MIDDLE MAIDEN SURNAME
Henry Herberg Winifred - Holland
70. WAS DECEASED EVER IN U.S. APMED FORCE57 ~ 19a. INFORMANT-NAME
or unk.~ III yes. give war and dates of serviced
IYe
1V 0 Ralph Galloway
t 9b. INFORMANT MAILING ADDRESS (STREET ORf1.F.D. NO., CITY OR TOWN. STATE, ZIPI
707 East 3rd ,Hastings, Nebraska 68901
20. LMER - NATURE 8 UCEN N 21 a. METHOD OF DISPOSITION 27b. DATE 21c. CEMETERY OR CREMATORY -NAME
1210 L.7 Burial ^ Removal 07/31/2001 ParkVlew Cemetery
.. FUNERAL HOM - N 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
Livingston- utlcr-Volland Funeral Home ^ Cremation ^ Donation Hastings
NE
,
22b. FUNERAL HOME ADDRESS iSTREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIPI
1225 N. Elm Ave. Hastings, NE, 68QU1
23. IMMEDI CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR IaI. ibl. AND ~c~I I Interval between onset and death
I
PART
I I
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DUE TO, OR AS C OUENCE OF: I Interval between onset and death
I
Ibl I
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DUE TO.OR AS EOUENCE I Interval between tinsel antl tlealh
I
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(c~ I
OTHER SIGNIFICANT CONDITI S - Conditions c Iributing to the death but not related PART III IF FEMALE. WAS THERE A 24. A OPSY 25. W ASE REFERRED TO MEDICAL
PART
II PREGNANCY IN THE PAST 3 MONTHS? AMINER OR CORONER?
.- (Ages 10.54 Yes Na Yes No Yes No
26a. 26b. DATE OF INJURY (Mo.. Day. Yr./ 26c. HOUR OF INJURV 26d. DESCRIBE HOW INJURY OCCURRED
Accident ~ Undetermined
M
Suicide ~ Pending 26e. INJURY AT WORK 261. PLACE QF INJURV - Al home, /arm, street. factory
i
i 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
Homicide Investigation
^ ^ ^
Y
N o ice build
ng, etc. /Spec
ty/
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27a. DATE OF DEATH /MO.. Day. Yr./ 28a. DATE SIGNED /MO.. Day. YrJ 2Bb. TIME OF DEATH
~,~ ~ '~ Sul ,-aw M
27b. DATE SIGNED /MO.. D . Vr) 27c. TIME OF DEATH y i k 28.:. PRONOUNCED DEAD (MO.. Day, Yr./ 2Bd. PRONOUNCED DEAD /Hour(
J D I Y
~g Vl l! M gi~° M
~ ~ 27d. To the st of y nowledge. death occurred et the ime, dale d p ce a ue 1 1
~ ° ~ ~
~ ° 7s 28e. On the basis of examination and/or investigation, in my opinion death occurred at
causelsl stated. the time, date and place and due to the causels~ staled.
ISi nature and TiNeI - Si nature and Title
29. DID TOBACCO USE CONTRIBU O THE DEATH? 30.a HAS N O UE ATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
^ YES NO ^ UNKNOWN YES ^ NO ^ YES NO
31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY( ~ /Type a Prinf) `,
32a. REGISTRAR 32b. DATE FILED BY REGISTRAR /Mo.. Day. Yc/
FOR VITAL STATISTICS USE ONLY
Place .......................A................................B................................C................................D...................
N SC ...................................................................................:........................................................................
Work .....:...........................................................................:.........................................................................
U C ...............................................................................................~...:..........................................................:.
Rf?iart
...........E ................................Part II......................TMV.............:.............
........................:........................................................... Census Tract No.