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HomeMy WebLinkAbout20080795NUM PGS `7" DOC TAX CK# FEES~QPD CK# ,,C~iG ~f ~CZ ACCT # O. ~ 9 RET FEES: CASH R.O.D. CK# REC'D/~ancN ~~~ ~¢""~ ,iu iiii ~u u u ui ~ A~AMSf~~I1XiKXf ms[rvq8080795 NUM ~a~.~.~_ Date,a- ~29o8~m 3:. 3P~ RETURN~Ffa~mA~E,e,(.~~~'~xre,V,s RD. COMP .,,.~_, 3'SG ~~~~~' }fgsrir/CrS , /1~~ G~qo / COMPARE ~ REGISTER OF DEEDS o~~u NEBRASKA CADAS _~ ~ s~.~/AO ~ DOCUMENTARY STAMP ,~ per. T~a~~-.~ RECORDERS MEMO: T'aFes 3~-~F AFFIDAVIT FOR TRANSFER are, e,o re s _ ~' ~ na~vres oc re, ~ # OF REAL PROPERTY WITHOUT PROBA no 9rr~ in a, otG ~ a_~q_o& UNDER NEBRASKA PROBATE CODE STATE OF NEBRASKA ) SS. COUNTY OF ADAMS ) The undersigned Affiant, upon being duly sworn, hereby deposes and states that: 1. This affidavit is given pursuant to Nebraska Probate Code Section 30-24,129. 2. Clark W. Hogate, also known as Clark Wheaten Hogate, deceased, died on December 15, 2007, as shown by the death certificate attached hereto as Exhibit A. He was a widower at death, as shown by the death certificate of his wife, Laura Jean Hogate, which is attached hereto as Exhibit B. 3. Affiant is the Decedent's daughter. 4. Affiant and the Decedent were co-owners of the following described real estate at the Decedent's death: Lot Seven (7), Block Three (3), Rohrer's Addition to the City of Hastings, Adams County, Nebraska, according to the recorded plat thereof. 5. The value of the Decedent's interest in all real property in the Decedent's estate located in this state, as shown on the assessment rolls for the year in which the Decedent died, does not exceed $25,000.00. 6. The value of the entire estate of the Decedent, less liens and encumbrances, is less than $25,000.00. 7. More than thirty (30) days have elapsed since the death of the Decedent. 8. No application or petition for appointment of a personal representative for the estate of the Decedent is pending or has been granted in any jurisdiction. i o~~ 20G80'795 9. Affiant is entitled to receive the Decedent's interest in the above-described real property by reason of the exempt property allowance and intestate succession, subject to the rights of any creditor to enforce a mortgage or other lien upon the real estate. 10. Affiant has made an investigation and has been unable to determine any will of the Decedent. ' 11. No other person has a right. to the interest of the Decedent in the above-described real property. 12. Affiant hereby swears or affirms that the statements contained herein are true and material and further acknowledges that any false statement may subject Affiant to penalties relating to perjury under Neb. Rev. Stat. Section 28-915. J. Sh on Pendergast 623 South Baltimore Hastings, Nebraska 68901 Affiant Subscribed and sworn to before me on February ~ , 2008. GENERAL NOTARY -State of Nebraska n~ RICHARD C. WIl'"f ~,,. - My Comm. Exp. 0 `. 13, 2010 Notary Public -2- 20~~ wHE ' STATE OF~NEBRASKA ,~ 0'G ~ U (°~ N;TH/S CORY CARRIES THE RAISED SEAL•OF'THE NEBRASKA HEALTH ANO HUMAMSERV/CES ' ~~HI B I T ~ A SYSTEM,'!T CERTIF, IES'THF BEL' OW:TO'BEA TRUE CORY OF THE'OR/G/NAL RECORD ON F/CE WITH THE NEBRASKA: HEALTH ANDi HUMAAf SERVICES SYSTEM, VITAL .STATIST/CS SECTION, WHICH !S ' ' TFIE;LEGAt DEPOS/TORY FOR VITAL RECORDS. ///J~~J DATECS OF ISSUANCE ~~~~ ~ "° "U Lv +?®G,~ ~ ~ ~~©.0~ TANLEYS. COOPER LINCOLN NEBRASKA ASSISTANT STATE REGISTRAR - I - HEALTH AND HUMAN SERVICES' STATEOF NEBRASKA-DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCEAND.SUPPC~gr7 -7 - - CERTIFICATE OF DEATH U 1 3 3/ 5 2 . ,1: OEC EOENT'S-NAME (First I • { Mitl dl e. Lael, -Suillx) ~" - 'Clark Wheaten HOgate 2.-S E% ~ - -- 3. DATE OF DEATH (MD:, Day, Yr.l - 4'. CITY AND STATE OR TEgRITORY, OR FOREIGN COUNTRY Male December 15,'2.007 OF BIRTH -:. 5a. AGE-Lest Birthday. gb. UNDER i YEAR ' ' ' Sc. UNDER i DAV g;"DATE OF BIRTH (MO Dey Vr ) : Blue' Hill, Nebraska (vra.> , 90 Mos.. ..oars HouRS ralNS. , ; . : February 8, 1917 '7. SOCIAL SECURITY NUMBER .:; , ge..PLACEOF DEATH ' 479-12-6156 :; .HO PITA : , ^ Inpallenl 9IldEfi: ~! Nursing Home/LTC Q Hospice.Faclllty tlb. FACILITY-NAME (I1 :not Inelllutlo n, give street and .nu mbar) - ~ - - - ^.ER/OUlpatledt : ^Deeedenl's Home Nebraska Veterans Home ; ^ ~~ ^ Other (Speclly) 8c. CITY OR TOWN OFDEATH (Include Zlp Code) - . ~ Grand I a land' Btl. COUNTY OFDEATH - 68803 _ Hall ': 9a. RE31DENCE-STATE - 9b CO Y - .Nebraska UNT . 9c. CITY OR TOWN :.Hall Grand Island - ~ ~,,9d.9THEETANDNUMBER. ~ ~ '. - ' ~ 9e. APT. NO - 91: ZIP CODE eg. INSIDE CITY LIMIT3 2300 West. Capital Ave. ' 68803 g1 YES ' ^ No- t0a. MARITAL STATUS AT TIME OF DEATH ^ Married • ^ Never Married 10b NAME OF SP . OUSE (Flrsl, Middle; Lasl, Suffix) II wile, give maiden name. - ~ ". ^ Married, Eat separated ~ Wldowetl ^ Divorcetl ^ Unknowri / l+auraJean Keller (deC ~, 17. FATHE R'. S-NAME. (First, Mlddl e, ' ~ Lest, .. Suffix) 12. MOTHER'S NAME (First, -- .M lddl e - , Malden Surname) Charles Hogate Etta '' Hadden :y13. EVER IN V.S. ARMED FORCES? Glve dates of service 11 yea. 14e, INFORMANT-NAME - 2 ~ 1943 4~ 19 ~ 1 9'43 140.-RELATIONSHIP TO DECEDENT ' T ~ 7~ ~ i~ . ( a , o; or , ) "Sharon Pendergast u Da ghter . 15. METHOD OF DISPOSITION 16a. EM ALMER-SIGNA UR ~ 160: LICENSE NO. ' ' 18c. DATE (Mo.r Day, Yr;) - ~urlal ODpnauon - ': 132.8 ~ December 19 . ~ 200 ' , ' ^Cfemallan ^Entombmenl l6tl. CEME7E ,CREMATORY OR HER LOCATION-~ _ CITY/TOWN STATE. ^Removel ^Olher (Speolly) Plainview Cemeter - " Y Bladen, Nebraska 1 17e. FUNERAL HOME NAME AND MAILINGADDRESS (Street; Clty ar iown, Slate) ( Livingston-Butler-Volland Funeral Home, 1225 N. Elm Ave_ Hastings,°NE17b68901 : '18.~PART.1. Enterfhe cneln olev t--diseases, Injuries; or complicallone-[hat tlirectly caused The death.DO tJO7 enter terminal ave la sud h _ n _ es cartllACerresl, ..APPRO%IMATE INTERVAL reapireloryeirest, or ventricular fl0rillatlon without showing the etiology. DO NOT ABBREVIATE: E t l - ' I ' n er on _ y one cause on aline: Addatltlltlonal Ilnes if neceseary.. I IMMEDIATE CAUSE: I ~ } onael to death I IMMEDIATE CAUSE(Flnel (a) End Stage Alzheimers .Disease ' X10 Years disease or c tll l ' . on t on resulting . DUE TO;.OR ASA CONSEQUENCE OF: ' ' In death) ~~ - - I onaetld death ... I '. Sequentially llal contlltlona, if (b) - I ". any, leading to the eause listed DUE 70, OR ASACONSEOUENCE OF: I on line a. _ .I onset to daelh ' Entertha UNDERLYING CAUSE ~ - ~ I ~ (dlaeeaa orin)ury that initialed ~. (°) ~ - ' _ I '. ~ ": t~fvenb resulting In death) DUE TO; OR AS ACONSEOUENCE OF: - .. (onset to dpath ' r 1e::~ PAR711..O7H ER SIGNIFICANT CONDITIONS-Contllllana contrlbulinp fo the death but not resulting In the undedying cause given In PART 1 ' . . : 19. WAS MEDICAL E%AMINER Y ~.C.I"]r0111.C O})St.YL1C-t.]..V2 P1111I1011ary ~D1SP~Se ~ OR CORONER CONTACTEDT. ^. YES .~ Np 20. IF FEMALE: - 21e.MANNER OF DEATH 210.IFTRANSPOgTATIONINJURY 21 c. WAS AN AUTOPSY PERFORMED? ~^ Not re ne l llhl e ~N ^ ' ' p g n w n p al year eturel HOmlclde ~ ' ^Drlver/Operator ^Pre9nenl et Alme of deelh ~ ^Paesengar •^ YES ' ~v0 ~. ^ACCident^Fentling lnveallgation ' ^ Nol pregnant, but pregnenl within 42 tlays of death ^ Pedestrian ' ^SUlcitle^Could ot bed l 21d WE n e armined . RE AUTOPSY FINDINGS AVAILABLETO ^ Nol pregnenl, but pregnant 43 days to t year Delore death ' - ^ Other:(Speclly) -' COMPLETECAUSE OF DEATH? Q Unknown II pregnenl within the peal year - ~ ~ ^ YES - ^ ~NO - - 22a. DATE OF INJURY (MO., Dey, Yr,) ~ 22b. TIME OF INJURY' 9 22c. PLACE OF INJURY-At home Term at a t, leclary ofllce 6ulltlin conatrucl( l tm , g, on s le; alb: (Specify) - 22d; INJURY.AT WORKT '. 22e. DESCRIBE HOW INJURY OCCURRED " 221: LOCATION OF INJURY-STREE76 NUMBER,APT NO._ CITY?OWN ~ STATE: - ZIPCODE - 23e. DATE OFDEATH (Mo., Day,Yr.) Z 24a: DATE SIGNED (MO., Day, Yr.) 24b. TIMEOFDEATH ~Y December 15 `2007 ' >~z m ~,i 236. DATE SIGNED.(MO., Day, Vr.) - 23d. TIMEOFDEATH ~5~ ~ J 24c. PRONOUNCED DEAD (Mo., Day,Yr.) 24d. TIME PRONOUNCED DEAD e o, Decem}~s 18, 2007 12": 35 A m aa s ~ , c 3 23tl: To the be 1 1 my knowledge, death o carted et the lime, data and place 'r+ w"~ ~ $ ' ie 24e. O Ih Beale of Inallon d/or Investlg tlon, In my opinion death occunad el .anddue to the cause(s) sleled.. (Signature entl Tllle) • $ ~ "Ihe time 1°- ~ ~ tlate and place entl due t ih ~ , o (~ / r°- @ cause(s) stated. (Signature end Tllle) ~- ~25. DID TOBACCO USE CONTRIBUTE TOTHE DEATH? - 28a.'HAS OgGAN OR TISSUE DONATION BEEN CONSIDERED? 266. WAS CONSENT GRANTED? ' ^ ~ ~ ~ / VES C~NO ^ PROBABLY ^~UNKNOWN '' ^ YE9 : -' W NO Nat Applicable ll Zea IS.NO ^ YES ^ NO. 27: NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN; CORONER'S PHYSICIAN OR COUNTY A770RNEY) (ry e or P i i . p n r ) Jennifer King M.D. `Nebraska Veterans Home,, Grand Island, NE 688.03 2Be;REGISTRAR'SSlGNATURE' "- 28b DATE FILED BY REGISTRAR (MO.; Dey, Yr.) ,(1. DEC 2 6 2007 ~m~~ WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTI'I AND HUMAN SERVICES ' ' ' SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY Of THE ORIGINAL RECORD ON FltE WITH EkH I B I'I B , THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH /S ' THE LEGAL DEPOSITORY FOR VITAL RECORDS. .; !~ ~ ' ; l~ DATE OF ISSUANCE r ANLEY S. 'COOPER OCT 5 2001 ' - ~ ~ ` ~ , `ASSISTANT STATE RAG/STRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM ' " ` ,:. is (, STATE OF NEBRASKA- DEPAR"IMEN-C OF HF.ALTFi AT7D HUMAN SERyICES FINANCE AND SUPPORT ~ I „c ', VITAL STATISTICS nnQ p CERTIFICATE OF DEATH r ~ Q ~ ~ U J I DECEDENT-NAME FIRST ~ MIDDLE LAST - 2 BEK 3 OA7E OF DEATH '(MOn~h Dal: Year) ~I Laura Jean Ho ate Female': September X20 2001 I ~ ,. d. CITY AND STATE OF RIRTH Ifl noln USA.. name counlryl 5a. AGE - Las10irthday UNDER 7 YEAR UNDER.1 DAV ~ .DATE OF BIRTH. /MonN. Oay. Year/ Des Moines, Iowa (Yrs.l7 ~ Sb. MOS. I DAYS Sc. HOURS I ' - MINS , 7 SOCIAL SECURTIY N M May ,20, 1922 U BER Ba. PLACE OF DEATH ~ - 482-14-5477 HOSPITAL: }{ __.__ ^ In alien( { ' a `~oTHER • ^ Nursing Hume Bh FACILITY ~ Name /I/nol mslifufion, give sheet and number) ^ ER Oulpahent ~ ~ ^ Residence St. Elizabeth's Regional Medi cal Cent r ^ . DoA ~ ^ tlther/spe~,r.r ' ' 6c CITY TOWN OR LOCATION OF DEATH Bd. INSIDE CITY LIMITS _. .. , ; Be COUNTY OF DEATH "-" ' ' y t Lincoln yes ® No ^ Lancaster " ; ' 9a. RESIDENCE -STATE 90. COUNTY 9c. CITY, TOWN OR LOCATION ~ 9d. STREET AND NUMBER /~nc/udmg Zp (:oriel i ; ~- 9e INSIDE CITY LIMITS ~ Nebraska Webs ter Blue Hill 602 NI "Seward "68930 ~B5 ^ Nn ^ ~ ~ 10 RACE - le.g.. While. Black. American Indian I t, gNCESTRV le.g.. Balian. e ~ $ Mexican, German, etc( 12. ©MARRIED . .. , ^ WIDOWED 13 NAME OF SPOUSE (f/wile. grve.marckg name) 2 ISpeay 1~ W ^ ~ NEVER _ / ' t ~~ ~ cE ' ~~ erman MAPRI Dlvoa D - ~ Clark W ~ Ho ate ~ Sr I4a USUAL OCCUPATION /Give kind o/ wwk done during moss t of working li/e. even it reliredl db. KIND OF BUSINESS INDUSTRY . 15~' EDUCATION ~ (Spec y only hlghesl grade completed) ' Homemaker Own Home Elementary ~$pco dory 10-i2) . - College It-d or 5.1 ' - ~ 16. FATHER -NAME FIRST MIDDLE I LAST 17. MOTHER ~ FIRST ~ .., . ~ 1,11DDLE MAIDEN SURNAME 1 Joe D. Keller Eva M. Royce 1B Y/AS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT-NAME - ~ Ives. no. or unk.l III yes. qwe war aril dales of serviced - ~ - No J. Sharon Fender ast '` 196. INFORMANT ~ MAILING ADDRESS IS7REET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) - 623 S. Baltimore, Hastings, Nebraska 68901' ~ ''-' 20, EMBALMER -SIGNATURE 8 NSE NO. 21a. METHOD OF DISPOSITION 21 b. DATE 21c CEMETERY tlR CREMATORY NAME c ~'~-~- y ~Bunal ^Remowal Sept. 24, 200 Plainview Cemetery 22a FUNERAL HOME -NAME 21d CEMETERY OR CREMATORY LOCATION ,..CITY OR TOWN STATE Livingston-Butler-Volland F.H. ^Cremation ^Donano^ Bladen-~ Nebrask'a '22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE. 21P) - ~ ..... , 1225 North Elm, Hastings, Nebraska 68901 , 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lat. Ibl. AND Idl - ~~ - - o- I ~ Inerval between onset and dean - PART '\ L I DUE TO. OR S A CONSEQUENCE OF I { I ., ~~ I Interval between onset and death Ibl ~vrcma.r ~ ~~S> ~ 'S~V t~ ~t`~St'~~ ~ cwcrul~~J- dr.Scz~UI,N ~~~~r~j DUE TO. OR AS A CONSEOU CE OP `0 rV /, C4~/' ~ I I ~ ~ervyal between onset and deals Ice ~: . / a _. OTHER SIGNIFICANT CONDITIONS - Cmdilions contributing to the death but not related PART III IF FEMALE. WAS THERE A 24 AUTOPSY ~ 25.,,WAS CASE REFERRED TO MEDICAL ' PART PREGNANCY IN THE PAST ]MONTHS? ~ ;EXAMINER OR CORONERn II (Ages 10-Shc Ves V No Yes No f Ves~ Na „' ' 26a 26b. DATE OF INJURY (MO.. Day. Yc/ 2fic. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED - :: ~ - : '~~ ACCitlenl ~ Undelermmetl ~ ,,. ,. ~ `'~,; M ~ ,~ '. Smcide ~ Pending 26e. INJURY AT WORK 261. PLACE OF INJURY - At home, term, sveel. laclory 26g. LOCATION STREET OR R.F.D. N0. ~ - CITY OR TOwN STATE ^ ^ o me buAding. etc. /Speciy/ - Homicide Invesegalion yes - No 27a. DATE OF DEATH /MO.. Day. YrJ 26a GATE SIGNED /Mp.. Day. YrJ ~ 2Bb. TIME OF DEATH - U ` - ` M , a = J 27b. DATE SIG ED (Mo ~Oay. Yr/ 27c. TIME OF DEATH $ i ~ 2BC. PRONOUNCED DEAD /MO. Day, Yr/ ' P&1. PRONOUNCED DEAD (Howl - 77 a~ rt 27tl To the best of my knowledge, d occurretl at the time, dale and place and due to the ~ o 0 28e. O the bases of exam alion and•or invesligahon in my oqn on deatn occurred al .- ,= causelsl slated. / "" T the I e dale and place and tlue to the causelsl staled - (S~ nature and Title(- ~ - IS nature and Title - ~ ' ~ ,? ~ ,~ 29 DID TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30 b WAS CONSENT GRANTED? s ^ YES ^ NO ~ UNKNOWN ^ YES ® NO .. ^ YES ~ - ~ NO 37. NAME AND ADDRESS OF CERTIFIER IPHYSIGIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEVI /Type or PnM/ ~~~LLL"' Eric A. Pe er, M.D. 1500 South 4 th St., Lincoln, 'Nebraska?68SG6 ,' ~ •~ 32a REGISTRAR J2b., DATE FILED BY REGISTRAR j/ o Da OCT ~ ~~