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CADAS - AO
ADAMS COUNTY, NE
FILED
INST. NO. ~UU~~~~~
Date,- ~- 08 Time~.~~
REGISTER OF DEEDS
Lot Seventeen (17), Block Three (3), Indian Acres Second Addition to the City of
Hastings, Adams County, Nebraska, according to the. recorded plat thereof.
~~ ~
STATE OF NEBRASKA 2 U 0 8 0 9 2
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, "WHPCH IS
THE LEGAL DEPOSITORY FOR VITAL RECORDS.
DATE OF ISSUANCE r 3 ' t° V r/ • -
a ( rI ~TANLEY S~~COOPER
II • ~~ !l .J. .~ 1 ~J U $ ASSISTANT 'STATE REGI S.TRAR
LINCOLN, NEBRASKA_ _ HEALTH; 4Nf~ HUMAN. SERVICE
STATE OFNEBRASKA-DEPARTMENTOF HEALTH AND HUMAN SERVICES FINANCE ANfSSUR~~F{Z, 2 0 7 9 4
Amended February 11, 2008 CERTIFICATE OF DEATH '. ~ CSJl ~
~\`~~
1}~ ~
P~ 1. DECEDENT'S-NAME (Flrsl, Middle, Last, Sufllx) 2. SEX ,t F DEATH (Mo.; Day; Yr.)
'9,~pATE O
)
~
`
Carl A Swearin en Male 27 2008
Januar
:
4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-last Birthday Sb. UNDER i YEAR 5c. UNDER i DAY 6. DATE OF BIRTH (MO., Day, Yr.)
(Yrs.) MOS. DAYS HOURS MINS.
Prairie View, Kansas 81 October 1, 1926
7. SOCIAL SECURITY NUMBER 6a. PLACE OF DEATH
HOSPITAL: ^ Inpatient 4ItiE6 ^ Nursing Home/LTC ^Hosplce Facility
Bb. FACILITY-NAME (II not Instltullon, give sheet and number) x
^ ER/Oulpatienl tai Decedent's Home
1620 Apache
^ DOG ^ Other (Specify)
fic. CITY OR TOWN OF DEATH (Include Zip Code) Bd. COUNTY OF DEATH
Hastin s 68901 Adams
9a.RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
"?' Nebraska Adams Hastings
,I~~~' 9d. STREETAND NUMBER 9e. APT. NO 91. ZIP CODE 9g. INSIDE CITY LIMITS
~~~
1620 A ache 68901 ~ YES ^ NO
t0a. MARITAL STATUS AT TIME OF DEATH ~Merrled ^ Never Mewled 10b. NAME OF SPOUSE (First, Middle, Last, Su11Ix) II wile, give maiden name.
^Married, but separated ^Widowed ^Dlvorced ^Unknown Marjorie Jensen
' 11. FATHER'S-NAME (Flrsl, Middle, Last, Sullix) 12. MOTHER'S-NAME (First, Middle, Maiden Surname)
Cha les -'~- Swearin en Mar ~~- L Hern
3 13. EVER IN U.S. ARMED FORCES? Glve dales of service it yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
(vas, no, or unk.) Y Mar'orie Swearin en Wife
15. METHOD OF DISPOSITION 16a.EMBRLMER-SIGNATURE 16b. LICENSE N0. i6c. DATE (Mo., Dey, Yr. )
^BUrlal ^Donalion 2/{ 2QQ$
~` ~'W, ~[Cremellon ^ Enlombmenl 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY /TOWN STATE
^Removal ^Olher(Speclfy) BV Cremation Center Hastings Nebraska
17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) Or m venue 17b. Zip Code
'
.
:: Livingston-Butler-Volland Funeral Home Hastings, Nebraska 68901
~
.. ~;r: ,
~'
gF 16. PART I. Enter the chain of events--diseases, Injuries, or complications--thel directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
I
respiratory arrest, or ventricular Iibrlllatlon wllhout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ilnes it necessary. I
IMMEDIATE CAUSE: I onset to death
•
~ ~ I
I
IMMEDIATE CAUSE(Final (al
~ disease or mndltton resulting DUE TO,OR ASACONSEOUENCE OF: I ~onsel to death
In death) I
" Sequentlelly Ilst conditions, it lb) I
,..~~~
,~ any,leading to the causellsted DUE TO, OR ASACONSEOUENCE OF: I onset to death
~' Rtf>N% on line e. I
EntertM UNDERLYING CAUSE
~?u +MU I
(dleease orln)ury that Initiated (c)
the events reeultingln death) DUE TO, OR ASACONSEOUENCE OF: I onset to deelh
WSf I
ld) I
~,
~ 18. PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
,-
fy'e! OR CORONER CONT/~,TED7
~I~F;
`s: ^ YES L_YfJ/O
'"~~'
W 20. IF FEMALE: 21e. MA ROF DEATH 21b.IF TRANSPORTATIONINJURY 21c.WAS AN AUTOPSY PERFORMED?
~' x
,
^ Not pregnant within past year alural ^ Nomicide - ^ Driver/Operator ~ /'
^
19'F
~,~ ~`.'
^ Passenger YES
O
W~
~ ^ Pregnant el time of death ^ Accldenl^ Pending Investigation
~~
^ Not pregnant, but pregnant within 42 days of death
^ Suicide ^ Could not be determined ^ Pedestrian
^
21d. WERE AUTOPSY FINDINGS AVAILABLE TO
w
^ Not pregnant, bm pregnant 43 days l01 year belore death
Other (Specily)
COMPLETE CAUSE OF DEATH?
- a. ^Unknown it pregnant within the past year ^ YES ^ NO
Ee.
~ ~ 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY-At home, larm, street, lactory, ollice tuilding, construction site, etc. (Specily)
~~' m
,,uH°:."
.. 22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
{
~F'~,~1~ ^ YES ^ NO
~,r
' 221. LOCATION OF INJURY -STREET 8 NUMBER, APT. N0. CITY/TOWN STATE ZIP CODE
(
,
t J.
23e. DATE OF DEATH (Mo., Day, Yr.) z~- 24a. DATE SIGNED (Mo., Dey, Vr.) 24b.TIME OF DEATH
z
as aZ
Januar 22 2008 au m
, v V o w
v } 23b. DATE SI ED (Mo., Day r.) 23c.TIME OF DEATH ~ = k 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
EaZ 5.55 P m E„a>Z m
' o m0
5 o¢F-O
23d. To the est of my knowledge, death occurred at the lime, dale and place ~ w z 24e. On the basis of examination and/or Investigation, in my opinion death occurred at
' a c and due 1 e cause(s) staled. (Signature and Title) • ~ p o the time, dale and place and due to the cause(s) staled. (Slgnelure end Title)
I? Q FoU
U O
~ ~' 25. DIDTOBACCO USE CO
IB
UT/~7OTHE DEATH? 26e.HAS OR OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
~~
/
^ YES ^ NO 4S PROBABLY ^ UNKNOWN
ES ^ NO ,~ /
Not Applicable it 26a is NO ^ YES IfI.M~
:~'~"4 27.NAME,TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY AT70RNEY)(Type or Prlnq
A` Jame W. Hervert, 2115 North Kansas, Hastings, Nebraska 68901
26a. REGISTRAR'S SIGNATURE ~ 26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
~• 3 2008
v
~~ HHS-61 11 /03 (55061)