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HomeMy WebLinkAbout20080838NU~A PGSi Z__ DOC THX CK#_______~ FEES • OD pp 1 . ~ ~ CK# oZ_63o I CHG -------_ ACCT #' Id_~ )"'" RET FEES: CASH R.O.D. CK#_____ RETURN ~a~r --'~"I ~-{,e IIIIIIVII~II~~n~Il~iNll'IN!lli~li~ i~UM _~!1~ RD. COMP ~25~ ~ ~='~~ COMPARE ~_ CAUAS ~ AO `~' ADAMS COl1NTY, NE FILED INST. NO.--~Q Dates-~-o8 Time l,_08 P•r~. ~~~~~ ~ REGISTER OF DEEDS Lots 21 and 22, In Block 3, In McKnight's Addition to the City of Hastings, ADams County, Nebraska. ~~ ~ STATE OF NEBRASKA 2 O U 8 Q 8 3 8i 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. ,/~ ~j~~ ' DATE OF ISSUANCE J4!y,, ~ r"""lJ ~ ' dy t\g ~ ~ ~flfltr? IYLEYS.;000PER 9'~EN UWt7 ASSIST,~N~~j~11~EREGISTRAR ..LINCOLN, NEBRASKA ' HEAD TH ND HLtiIAN ~ERV/CES 'STATE OF NEBRASKA -DEPARTMENT OF HEALTH aANd~HUMAN SERI~ICES'a ~ CERTIFICATE OF DEATH , $ ~ QJ ©' 1 DECEDENTS NAME (Firs Mld -. t. die, Lasf, Suffix) : "~~ ~~.g .~} 3 DATE OF DEATH (Mo.,Day Yr.) t , Garold D Moser ~ ~ - ' Male ' .~ January 16, 2008 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH S ' ' a. AGE•Last Birthday Sb. UNDER~ ti~ AR; •k. UNDER 1•DAY ;. 8. DATE OF BIRTH (MO., Day, Yr.) (Yrs.) MOS. ^~ DAY$-. '%HOU S, - ~MINS'{ Bloomington, Nebraska 73 '' ' January 3, 1935 7 . SOCIAL SECURITY NUMBER 9a. PLACE OF DEATH ~~'... ~ 5115"38-6545 HOSPITAL: ^ Inpatient } OTHER:.^ Nursing:Home/LTC ^ Hospice Faclllty 8b. FACILITY-NAME (If not Instllutlon, glue street and number) ^ ER/Outpatlant ®Dac'~dent's Home ~ 1000 Oswego Ave p DOA ^ Other(SpeeHy) Bc. CITY OR TOWN OF DEATH (Include Zip Coda) ed. COUNTY OF DEATH j Hastings 68901 U Adams ~ LL 9a. RESIDENCESTATE 9b. COUNTY 8t. CITY OR TOWN Nebraska Adams Hastings •p d 9d. STREET AND NUMBER ~.~ ,... 9e. APT. NO. 9f. ZIP CODE 9g. INSIDE CITY LIMITS w 1000 Oswego Ave 68901 ®Yea ^ No Z ' t0a. MARITAL STATUS AT. TIME OF DEATH ^ Married ^ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Su1Nx) If wHa, give maiden name D . ,,v, ~"-<^ Marcied, but separated ®Wldowed ^ Divorced ^ Unknown . tD Coralee Madrid c E O 11. FATHER'S-NAME (Flrat, Middle, Last. Suffix) 12. MOTHER'S•NAME (First, Middle, Malden Sumama) ~ m Fred Moser Alice Shelton m 17. EVER IN U.S. ARMED FORCE54 Glve dates of servlca ff Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP 70 DECEDENT O H (Yea, No, or unk.) Yes 09/14/1954-09/14/1956 Amy Casele Daughter 15. METHOD OF DISPOSITION 1Ea. EMBALMERSIGNATU E 76b. LICENSE NO. 18c. DATE (MO., Day, Yr.) ®Bunal ^Donatlon ~ ~ ~~~ ^Cmmatlon ^Entombm.nt January 21, 2008 ^Removal ^Othsry9pecify) 18d. CEM TERY, C MATORY OR ER LOCATION CITY/TOWN STATE Clay Center Cemetery Clay Center Nebraska 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Sirea4 City or Town, Stale) ~ 17b. Zip Code Brand-Wilson Funeral Home, 505 N Bellevue Hastings Nebraska , , 68901 CAUSE OF DEATH (See instructions and examples) 1a. PART I. Enter the chain o/eyenh -tliesasee, (n)udes, or compliratlona• that tllrsdly reused the death. DO NOT enter terminal ewme ouch as raMlae amat, PPPROXl,MATE INTERVAL respiratory arrest, or ventricular abdlladon wlthoul showlnp the etlolopy. DO NOT ABBREVIATE. Enter only one uuw on a Ilne. Atltl atltlitlonal lines It nspseary. IMMEDIATE CAUSE; I onset to death IMMEDIATE CAUSE (Final disease or condltlon resulting a) (~/~ 1 n ( ~ 4' ~~ ~l 'e' I~k 1 M ' I')'''dYl ,l'r• u . fiJ 7YY In death) 1 t 1 (~/ DUE TO, OR Aa^ A CONSEQUENCE OF: i ; onset to death Sequantlally Ilst conditions, If b) any, leading to the cause Ilsted on line a. DUE TO, OR AS A CONSEOUENCE OF: ~ onset to death Enter the UNDERLYING CAUSE c) (disease or Injury that Initiated the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: :corset to death LAST d) 18. PART II. OTHER SIGNIFICANT CONDITIONS-CondlUons contributing to the death but not reselling In the underlying suss given In PART 1. 19. WAS. ~T~jtjICAL EXAMINER OR CDRONER CONTACTED? ^ YES ~ NO ~ W LL 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED? F- ^Not pregna nl within past year ^ Natural ^ Homicide ^ Driver/Operator ^ YE5 ~ NO W ^ Pregnant at time of death ^ A U ^ Not pregnant, but pregnant wilhln 42 days of death ccident ^ Pending Investlgatlon ^ Suiclda ^ Could not be determined ^ Passenger ^ Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE a ^ Not pregnant, but pregnant 43 days l0 1 year before deat ^ Other (Spaclfy) TO COtdPLETE CAUSE OF DEATH? ^ YE,`.i ®NO y ^Unknown If pregnant within the past year d a C 22a. DATE OF INJURY (t4o., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY•Al home, farm, street, factory, ofnce bullding, eonstruction silo, nte. (Specify) U v m O _ 22d. INJURY AT WORKS 22e. DESCRIBE HOW INJURY OCCURRED F' ^ YES ^ NO I 22f. LOCATION OF INJURY -STREET & NUMBER, APT. NO. CITY/TOWN STATE ZIP CODE 23a. DATE OF DEATH (Mo., Day, Yr .) Z 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH Q m ~~ ~ ~ t7a V ~ ~''~i _ :: N 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DFATH d > O 24c. PRONOUNCED DFJ1D (Mo., Day, Yr.) 24d. TIME r'RONOVNCED DFAO o~z , .~~. ~-oE~ 11:14 P m E~<z m o , O ' y y 23d. To the best of my kn wledge, death occurred al the time, date and place ~ W = 24e. On the basis of examination and/or Investlgatlon, In my opinion death occurred G ~ and due to the cause(s) stated. (Slgnamre and Title) a O =O at the time, date and place and due to the caus:,(s) stated. (Signature and Title) ~ ~ ~ ~" ~ cOU H riy, ~P(Y!GC1~y ~ U o 25. DID TOBACCO SE CO TRIBUTE TO THE DEATHS 28a. NAS ORGAN OR TISSUE DONATION BEEN CONSIDERED4 26b. WAS CONSENT GPANTED4 ^ YES ®NO ^ PROBABLY ^ UNKNOWN ^ YES ® NO Not Applicable If 26a is IvU ^ YES ~ NO 27. NAME, TITLE AND ADDRESS QF CERTIFhERa(PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print) er i Jon h g a Pornc , MrD., 815 N. Kansas Ave, Hastings, NE 68901 P 29a. REGISTRAR'S SIGNATURE 1 ~ 2Bb. DATE FILED BY REGISTRAR (Mo., Day, Yr.) ~ .~~t,!i,~~,, ,~ .IAN 2 3 200 I ~t~ ~ ~I ~ ~ a a .Z J '~