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HomeMy WebLinkAbout20080211NUM PGS DOC TAX CK# PEES/Cf; Sc~ PD So CK# SDI t CHG ACCT # RET FEES: CASH R.O.D. CK# RECD pAm - l~j,~Ams Lgnt ~ -f'c f'Ic. RETURN .4riarns L.-a.rlo Ti~~c F1S nnc o $ QDI u~~uun~~~~~~~ NUM ~"~r~ .~~ S_; / RD. COMP _ X tiu COMPARE / OIRJ CADAS ______, AO _._._'~' ,._ ADAMS~COUNTY, NE INST. N0.~0 2 i 1 Date.,~1tZ..Time-„ ~~i°.~2 REGISTER OF DEEDS 2oo$o~il AFFIDAVIT FOR TRANSFER OF PERSONAL PROPERTY WITHOUT PROBATE UNDER NEBRASKA PROBATE CODE STATE OF NEBRASKA ) ss. COUNTY O.F ADAMS ) The undersigned affiant, upon being first duly sworn, does hereby depose and state: 1. The value of the entire estate of Cheri V. Pittman, deceased, wherever located, less liens and encumbrances, which is subject to probate proceedings, does not exceed $25,000.00. 2. Thirty days have elapsed since the decedent's death and a certified copy of decedent's death certificate is attached hereto and made a part hereof. 3. No application or petition for the appointment of a personal representative is pending or has been granted in any jurisdiction. 4. Affiant is entitled to payment and delivery of all property held by others in the sole name of the Decedent pursuant to Nebraska Probate Code X30-24,125 and that affiant's entitlement is based upon affiant's status as spouse of the decedent. 5. Pursuant to Nebraska Probate Code X30-24,126, the person paying, delivering, transferring or issuing personal property or the evidence thereof pursuant to this Affidavit is discharged and released to the same extent as if said person dealt with a personal representative of the Decedent;- said person is not required to see to the application of the personal property or evidence thereof or .to inquire into the truth of any statement in this Affidavit. _ ...._.. DATED this 7th day of Janu r ....--~~-" 2008 /`` .-Daniel J. Pittman SUBSCRIBED AND SWORN to before me n anuar ~~`• ~ 008 GENERAL NOTARY -State of Nebraska ~~,' ~ ~G~ G MICHAEL W. KASSEBAUM o t a r y Pub i s _ M Comm. . March 5 2009 /~ z ~3~7 [734 ~ooso2ii A tract of land comprising a part of Lot One (1), Pittman Subdivision in the City of Hastings, Adams County, Nebraska, said tract being more particularly described as follows: with reference to the Northwest corner of said Lot One (1), Pittman Subdivision, said point being on the South line of "J" Street in said City of Hastings, thence running N 89° 09' S5"Eon the South line of "J" Street for a distance of 46.78 feet, thence N 72° 46' 03"Eon the South line of said "J" Street for 6.76 feet to the actual POINT OF BEGINNING: thence S 49° 24' S9" E for 11.87 feet; thence S 04° 19' 11" E for 82.24 feet; thence S OS° 50' 21'--' W for 82.48 feet; thence S 03° 59' 40" E for 81.13 feet; thence S 11° 30' 20" W for 83.88 feet; thence S 47° O1' 47" E for 8.12 feet; thence S 29° 25' 40" W for 85.60 feet; thence S 52° 38' 13" W for 16.35 feet to a point on the West line of said Lot One (1); thence S 00° O1' 07"Won the West line of said Lot One (1) for 2.27 feet to the Southwest corner thereof; thence N 89° 28' 39"Eon the South line of said Lot One (1) for 261.36 feet to the Southeast corner thereof, thence on an assumed bearing ofN 00° 00' 00"Eon the East line of said Lot One (1) for 457.85 feet to the Northeast corner thereof, said point being on the South line of said "J" Street; thence S 89° 27' 00"Won the South line of said "J" Street for 104.71 feet; thence S 72° 46' 03"Won the South line of said "J" Street for 108.13 feet to the POINT OF BEGINNING. WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES p THE NEBRASKA HEALTH AND UMAN SERVICES SYSTEM, VITALS AT STICS ~-C~ O_ _N,F~ICH 1S ~ O o p Q 2j i THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ - Xr/ `~_ - DATE OF ISSUANCE - - ~ ` r/~A~~ANLEY S C08PER 6/ 2/ 2 0 0 4 ass-SrAn~s~~a ~E -~~,isT~AR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM _- _,J, , _ -, . STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERt~ICES~INANCE A2dEhES SL~FPORT VITAL STATISTICS - _-- 0 4 0 5 7 4 7 CERTIFICATE OF DEATH - - - __ 11. DECEDENT-NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF DEATH - lMonlh. Day. Year) Cheri V. Pittman Female May 23, 2004 4. CITY AND STATE OF BIRTH 111 not in U.S.A.. name country) 6a. AGE -Last Birthday UNDER 1 YEAR UNDER 1 DAY 6. DATE OF BIRTH /Month. Day. Year) I Grand Island, Nebraska (Vrs.l 6 47 b. MOS. DAYS ' Sc. HOURS' MINS. November 2, 1956 7. SOCIAL SECURTIY NUMBER Ba. PLACE OF DEATH HOSPITAL: ^ Inpatient OTHER: ^ Nursing Home 505-74-8174 6b. FACILITY -Name /1/rot institution, give sheet and number) ^ ER Outpatient ^ Residence MM 357 I-80 ^ DOA ~ Other /SPecrtyr Hl Way Bc. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CITY LIMITS 6e. COUNTY OF DEATH / ~~ 7 I-80 ~/y/ Yes ^ No © York , „ 9a. RESIDENCE -STATE 9b. COUNTY 9c. CITY, TOWN OR LOCATION 9d. STREET AND NUMBER (Including Zip Code/ 9e. INSIDE CITY LIMITS Nebraska Adams Hastings 2815 So. Ridge Rd. 6890 1 Yes ^ No 10. RACE - le.g., White. Black. American Indian. 11. ANCESTRY le.g.. Ilallan. Mexican, German, elcl 12. ®MARRIED ^ WIDOWED 13. NAME OF SPOUSE /1/wile. give maiden name) etc./ lSpecily) White (Specify) German/Irish NEVER DIVORCED Daniel Pittman MAR, 14a. USUAL OCCUPATION (Give kind of work don e during mos/ 14b. KIND OF BUSINESS INDU STRY 16. EDU CATION (Specify only highest grade compleledl o/ working file, even r7 retired) ~ Elementary or Secondary 10-12) Colle a 11-4 or 5'I Homemaker/co-owner Own Home/Exterminatin Co. 12 L 16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME John Volkmer Jackie Lewis 16. WAS DECEASED EVER IN U.S. ARMED FORCES? f9a. INFORMANT-NAME (Yes. no. or unk.) III yes. give war aM dales of services) No Daniel J. Pittman Husband 19b. INFORMANT MAILING ADDRESS ISTREE7 OR R.F.D. NO., CITY OR 70W N. STATE. ZIP) 2815 So. Rid e Rd., Hastin s, Nebraska 68901 20 LME SIGNATURE 8 UC O. ~~ 121 O 21 a. METHOD OF DISPOSITION 21 b. DATE 21 c. CEMETERY OR CREMATORY ~ NAME ~ ^ Burial ^ Removal M 6 2 I - UNERAL 21 d. EMETERY OR CREMATORY LOCATION CITY OR TOWN STATE ~ Cremation ^Donalion Livin st n-Butte -V lla F H 22b. FUNERAL OME ADDRESS ISTREE7 OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP) 1225 N. Elm Ave H s N s O1 23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lat. Ib), AND (cll I Interval behveen onset and tleath I PART 'IalBlunt Trauma To Head, Chest and Extermities ; Immediate DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset antl death IblMotor Vehicle Collision DUE TO, OR AS A CONSEQUENCE OF ~ I Interval between onset antl death I (cl I OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not related PART III IF FEMALE. WAS THERE.A 24 AUTOPSY - 25. WAS CASE REFERRED 70 MEDICAL PART ~ PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER? II (Ages 10-64) Ves No Ves No Yes No 26a. 26h. DATE OF INJURY /Mo.. Day. Yi.J 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJJRY OCCURRED ® Accident ~ Undetermined May 23, 2004 9:43 A M Motor Vehicle Collison Suicide ~ Pending 26e. INJURY AT WORK 26t. PLACE QF, INJDRY - At hom , /arm, slreeL lackxy ci/ f Po b ld t (S 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE Homicide Investigation Yes ^ Np ~ y ce m mg, e c. pe o Highway MM 357 I-80 York County, Nebraska DEATH (MO.. Day. Yr.J F 27a. GATE O 26a. DATE SIGNED /Mp.. Day. YrJ 26b. TIME OF DEATH ~~ ~~ g ~/( -~' ~ 27b. DATE SIGNED /MO.. Day. YcJ 27c. TIME OF DEAT H ~ ~ < } 28c. PRONOUNCED DEAD /Mo.. Day, Yc/ 26d. PRONOUNCED DEAD /Houd °~'° I?2a i1J ~700~~ p M /•' ~~~0 8'z ~ 9:50 A M a~ 27d. To Ih best of my'knowled .death occurred a lime, date and place and due to the ° ~ ° 2Be. On the basis of examination antl~or investigation, in my opinion death occurred at ~ causelsl slated. }j Y ~ (\'~ 1 //~J ~~J ~ ~ ~ v the lime, date and place and due to the causalsl stated. ~ ~ _ ~ (Si nature and Tillel -.lJ~CG~cF'"CJ ~y ~ ~ (Si nature and Title/ - See item 2 7 d 29. DIO TOBACCO USE CONTRIBUTE TO THE DEATH? 30.a HAS ORGAN O ~~SSUE DONATION BEEN CONSIDERED? V' 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 aPrin7J ale E. Radcliff, York Count heriff, 10 incoln Ave., York, Nebraska 68467 32a. REGISTRAR ~ ~ 32b. DATE FILED BV_?EGI~ A.~/~ D yoo~ ~ TI