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ADAMSF OUNTY, NE
INST. NO ~~08U~~~
Dateo~,nme.~0 AM
`~~~'
REGISTER OF DEEDS
RESERVED FOR REGISTER OF DEEDS RECORDING-SPACE
ADAMS COUNTY NE
The East One Hundred Fifty (E 150) feet of the South Ten (5,10) feet of the North
Half (N 1/2) of Block Seven (7), and the East One Hundred Fifty (E 150) feet of
the North Fifty-Six (N 56) feet of the South Half (S 1/2) of Block Seven (7), all in
Alexander's Addition to the City of Hastings, Adams County, Nebraska,
according to the recorded plat thereof.
~c5
PAGE 1 OF ~ PAGES
STATE OF NEBRASKA 2 O O~ O S 2i ,~.-
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.
DATE OFISSUANCE ~
AUG 0 8 "2007 ASSISTANT S ALTE REG S~RAR
LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES
STATE OFNEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUP~q~ ~ ~ ~ ~y
CERTIFICATE OF DEATH / tj t f
1, DECEDENT'S-NAME (First, Middle, Leal, Sulflx)
Clark Allen Spanel 2. SEX' 3. DATE OF DEATH (MO., Day, Yr.)
Male Jul 24,2007
4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday 5b. UNDER 1 YEAR Sc. UNDER 1 DAY 6. DATEOF BIRTH (Mo., Day, Yr.)
Grand Island, Nebraska (vra:) MOS. DAYS" HOURS MINS.
25 Febr. 5,1982
7. SOCIAL SECURITY NUMBER Ba.PLACEOFDEATH
505 - 11 - 5324
HOSPITAL: ^lnpatient ~ ^NUrsingHome/LTC ^HosDiceFacilify
fib. FACILITY-NAME (II not Instltutlon, give street end number)
^ ER/Oulpatlent ^ Decedent's Home '
U S Highway 34 & County, Road 365
^ ~,, 2q omer(spenny) Highway 34
8c. CITY OR TOWN OF DEATH (Include ZIp Code) ', 6d, COUNTY OF DEATH
Trenton, Nebraska Hitchcock,. Count
"
9a. RESIDENCE-STATE 9b.000NTV 9c. CITY OR TOWN
Nebraska Adam
s Hastings
'
9d. STREETANDNUMBER ~
815 North Lincoln 9e. APT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
68901 lx YES ^ No
- t0a. MARITAL STATUS AT TIME OF DEATH C~Married ^ Never Married
I 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name.
^ Mewled, but separated ^ Widowed ^ Divorced ^ U;nknown
" La c r i t i a We 1 k e
11. FATHER'S-NAME (Flral, Middle,. ~i Last, Suffix)
Mart
-': ~: S
al `~ 12. MOTHER'S-NAME First, Middle-,
( Maiden Surname)
y
an
I Darc =~_° Frauen
13. EVER IN U.S. ARMED FORCE51 Glve dates of service I(yes. 14a. INFORMANT-NAME 1
b
w
(Yea,nn, nrunk.) No ~ ,
Lacri tie. Spanel 4
. RELATIONSHIP TO DECEDENT
Wife.
15. QMETHOD OF DISPOSITION-
4t Burial ^Donallon 16a. EM LMER-SIGNATUR
f
~~ 16b. LICENSE N0. 16c. DATE (Mo., Day, Yr. )
~,
~,,~~,~ 699 Jul 28 2007
^Crematlon ^Entombmenl 6d.CEMETERY,Oi EMATORYOROTHERtOCATION CITY/TOWN ~ STATE
yl
- ^Removal ^omer(specuy) Grandl Island City Cemetery, Grar.d Island, Nebraska
17a. FUNERAL HOME.NAME AND MAILING ADDRESS (Str~et, City orTOwn, State) 17b. ZIp Code
All Faiths Funeral H
2929
one,
So. Locust St. Grand Island, eb.68801_
1fi. PARTi. Enter the chain of event.--diseases, InJurles, or c6~npllcatlons--that directly caused the death. DO NOT enter terminal events such as cardiac arrest; APPROXIMATE INTERVAL
respiratory arrest, or ventricular librillationwlthout showing the etiology, DONOT ABBREVIATE. Enleronly oneceuse on a line. Add additional lines if necessary
. I
IMMEDIATE CAUSE: I onset to death
~~i
IMMEDIATECAUSE(Flnel (a) Severe }lead and upper body trauma ' Immediate
dlaeaseorconditlonreaulting DUE T0, OR AS A CONSEQUENCE OF;
In death) ~ I onset to death
A Motor Ve
hicle collision
p
Sequentlellyllstcondltlons,IF (b)
~ I
M
any, leading to the cause listed I
DUE T0, OR AS A CONSEQUENCE OF:
on Ilne a
.
I onset to death
1
Enter the UNDERLYING CAUSE
I
(dlaease or lnJury that lnllleted (o) !i I
the events resulting In death) DUE T0, OR AS A CONSEQUENCE OF:
.LASE
~ I onset to death
(d) ~ I
18. PART 11, OTHER SIGNIFICANT CONDI710NS-Conditions oontributing to the death but not resulting in the underlying cause given In PART I. 19. WAS MEDICAL EXAMINER
k
~. O
R CORONERCONTACTED7
~t
`~~~ JN "YES ^ NO
20. IF FEMALE: ~,~ , 27a: MANNER OF DEATH 21b. IFTRANSPORTATIONlNJURY 21c. WAS AN AUTOPSY PERFORMED?
^ Notpregnanl wllhln past year j. ^ Natural ^ Homicide ~ DrivedOperator
^Pregnent at lime oldeaih ~~,I zc
s] Accident^ Pending Investl
etlon
` ^Passenger ^YES ~I NO
g
^
Not pregnant, but pregnant within 42days of death
^ Suicide ^ Could not be determined ^ Pedestrian
21d. WERE AUTOPSY FINDINGS AVAILABLE TO
^ No! pregnant, but pregnant 43 days to 1 year before death '{i " ^ Other (Specify)
I
- ^ Unknown II pregnant wllhin the pall year 1 COMPLETE CAUSE OF DEATH?
- - - ^ YES ~NO
22a. DATE OF INJU ~Y (Mo., Day, Yr.) J
22b. TIyE 2 22
Al ho
farm, street, laclory, ollice building, construction site, etc. (Specify)
AD
Jul 24 2007 5
Am 3
U S
Hl ghwa
' 22d:INJURYAT WORKS 22e. DESCRIBE HOW INJURY OCCURRED ,
AYES ^NO Motor vehicle accident
221. LOCATION OF INJURY -STREET & NUMBER, APT: NO. CRY/rOWN
STiSiE ZIP CODE
.5 mile East of MM 61 US Hi hwa 34 rural Hitchcock Co nt (Nebraska
23e. DATE OF DEATH (Mo., Day, Yr.) _ ~ 24a. DATE SIGNED (Mo., Day, Yr.) 246.TIME OF DEATH
d~ au¢ Jul 30, 2007 j 9:25 a. rn
m>~ 23b. DATE SIGNED (Mo., Day,Yr.) 23c.TIMEOF DEATH $_~ 24c. PRONOUNCED DEAD (Mo., Day,Yr.)~ 24d. TIMEPRONOUNCED DEAD
o F" E» Z Jul 24, 20C7 9 c 38 a. m
:0 23d. To the best of my knowledge, death occurred et the time, date and lace ~ ¢ Z o
~ end due to the cause(s) slated. (Signature and Title) • p ~ z ~ 24e. On the basis of examinatinn end/or investigation, in my opinion death occu«e
°
a F ¢ U the time, date end place and a to the se(s) stated. (Signetureand Title )
r
-
:tleYlff~~Y
~
~
V
Cf1er•
•,
.a,
o
25. DIDTOBACCO USE CONTRIBUTETOTHE DEATH? 26a. HA50RGAN OR TISSUE-DONATION BEEN ", ONSIDERED7 126b. WAS~CONSENT GRANTED
^ YES ~1 NO ^ PROBABLY ^ UNKNOWN ^ YES RI':NO
27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN
CORONER'SPHYSICIAN OR COUNT Not Applicable 1126a Is NO ^ YES NO
,
Y ATTORNEY) (Type
D. BRYAN LEGGOTT Hitchcock Co. Sheriff, Court rPrinf) ~~~~Q, $OX 3O6
ouse, TYenton, Nebraska 69044
28a. REGISTRAR'S SIGNATURE -
~~~'
1~ ,(
~ •
, 2fibi DATE FI~.ED BY REGISTRAR (Mo.,
Day, Yr.)
AU G 3 2007
7
vroc.