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40 <br />200107460 <br />The East Half (E' /2) of Section Twenty -two (22), Township Twelve (12) North, Range Twelve (12) West of the 6111 P.M., Hall County, <br />Nebraska Excepting a certain tract more particularly described in Deed recorded in Book 77, Page 1140 and Excepting a certain tract more particularly <br />described in Deed recorded as Document No. 96- 100643. 1 <br />94 sTATB OF MRASRA. DVARTM IWT OF WALTH AND HUMAN SERVIMS FDLANM Am suPi'ORT28 `2 249 <br />V[rAL STATLSTK3 <br />CERTIFICATF. OF DEATH - <br />1. DECEDENT - NAME FIRST � MIDDLE LAST — <br />2. SEx <br />1 DATE OF DEATH 1661(/! . VVW <br />Sarah S. Rich <br />Female <br />January 08,1998 <br />4 AND STATE OF BIRTH !a rot n U S.A. AW* CdanYl <br />5► AGE - Lao &M"y <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH Abri t Day. YW <br />Rural Cairo, Nebraska <br />ry (&' 59 <br />5b MOS I DAYS <br />SC. HOURS MINS <br />January 10, 1938 <br />7. SOCIAL SECURITY NUMBER <br />6a PLACE OF DEATH <br />505-42-4115 <br />HOSPITAL. ❑ wweeen OTHER. © WMN HWM <br />❑ ER OuVaUra ❑ Residence <br />69. FACILTTY - Name /Mror vbm*m 7W teeaf and M0081 <br />Bergan Respite Care <br />❑ DGA ❑ O6br lsoetal <br />6c CITY TOWN OR LOCATION OF DEATH <br />6d INSIDE CITY LMNTS <br />6 <br />Omaha <br />YW ® Nd 1:1 <br />ouglas <br />S•. RESIDENCE - STATE <br />9b. COUNTY <br />9e. CIT/, TOWN OR LOCATION <br />9d. STREET AND NUMBER ry._1U**Zle Come/ <br />9e INSIDE CITY LIMITS <br />Nebraska <br />Douglas <br />I Omaha <br />13418 S. 102nd Street, 68132 <br />Yea ❑X No ❑ <br />10 RACE - lap.. Wlfae. BlaCk. Amere4n Man, <br />11. ANCESTRY lag.. 6aken. Mealcan. Gem w. at) <br />12 ❑ MARRIED O WIDOWED <br />13 NAME OF SPOUSE 10 w11e Aye meoke- n&vW <br />C auc slan <br />I American <br />N�� DIVORCED <br />14a USUAL OCCUPATION /GM brd d ware dine Ang mdY 14b <br />KIND OF BUSINESS INDUSTRY <br />15. EDUCATION ISOectj dMy Ie UN grade carobledl <br />Ebrff r a SecaNny 10-12) co" 11- W 5.1 <br />11 LL <br />d wa*.v M►. ow Y reirwi <br />VicePres. /Sec./Treas. <br />Rich Brothers Electric <br />16. FATHER - NAME FIRST MIDDLE UST <br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME <br />George DeSoe <br />Mildred Stoeger <br />1• WAS DECEASED EVER IN U.S ARMED FORCES? <br />194 INFORMANT -NAME <br />ryas. no. a to k) IN yea . Wft w and dabs d servCMI <br />No <br />Brian Rich <br />19b INFORMANT MAILNG ADDRESS (STREET OR RF.D. NO.. CT' OR T(WYN. STATE 21P1 <br />�eaard QmahshF6 68111 <br />20. EMBALMER - SIGNATUgE 6 LICENSE NO <br />21 a METHOD OF DISPOSITION <br />21D DATE 21c <br />CEMETERY OR CREMAT DRY NAME <br />.f \]f" �? �-3 <br />® &.,.I ❑ R.md„al <br />01/12/1998 <br />Hillcrest Memorial Park <br />221 UNERAL HOME . NAME <br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Boyd E Braman Mortuary <br />❑ `°nf'' ❑ °" <br />Omaha, Nebraska <br />22. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CRY OR TOWN. STATE 27?) <br />1702 N 72nd Street Omaha, <br />as IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR la) - IOU AND (tll 1 IrAwal between cram and deM <br />PART ME)-AS c 110C?VOC f" -iANA" Or 7W evLuA.) ! * V&fes <br />DUE TO. OR AS A CONSEQUENCE OF - I Ir"mal be w" 011M1 A W damm <br />I <br />I <br />DUE TO, OR AS A CONSEQUENCE OF I Yft 21 bel~ on w DAM deal" <br />I <br />I <br />IOU <br />OTHER SIGNIFICANT CONDITIONS - Cadv" s WM b*V b eb ODM bA n01 rdaled <br />PART ■ IF FEMALE. WAS THERE A <br />24 AUTOPSY <br />25, WAS CASE REFERRED TO MEDICAL <br />PART <br />PREGNANCY N THE PAST 3 MONTHS? <br />EIWMNER OR CORONER' <br />6 <br />(Ages 10.54) Yea No <br />Yes No <br />Yea No <br />Ma <br />23b. DATE OF F 1URY Albs. A,Ay, Y�' <br />ne HOUR OF INJURY ,. i 26Q DESCRIBE HOW INJURY OCCURRED <br />❑ AecWtM o Ur4oW 18d <br />yM` `. <br />O. M <br />C] Suede PenOi rp <br />264. PW*Y Aj <br />1vm. WOOL %My <br />264 LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />1201. <br />2?a DATE OF DEATH Ma. Day. YM .. 1 1 <br />211 DATE SIGNED /Yo_ Day Yrl <br />26D TIME OF DEATH <br />v <br />�itNG1 A !e Y P (9 ��- <br />M <br />a <br />27b. DATE SIGNED Ala. Day Yr <br />a 7iLiEbF DEATH <br />2l)c. PRONOUNCED DEAD /Mo.. DeY, rii <br />264 PRONOUNCED DEAD lNwl <br />M <br />IS <br />270 o sw bbl d nj <br />•l <br />Ma On 6b btais d ewnneaon analor MuagaaaL N Kry epreal Oea61 ootuls6 r <br />• <br />.°- <br />_ <br />CnrNal slMSa <br />a <br />M ". daft arW *ft and dw b ft CauWUI Wba <br />y/ <br />and <br />YW T11N <br />M. 010 <br />TOBACCO USE TO THE OFATW 301k KWIORGAN OR TIME DONATION BEEN <br />D? <br />30d WAS CONSENT GRANTED? <br />❑ YES <br />YES 1:1 in "N, <br />YES <br />1:1 Lt:j No <br />31. NAME AND ADDRESS OF CERTIFIER IPHYSOAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) Irwe a ftv <br />pE Igw' 4 E /I�IOS %EK x'19" S(D/ E: 6(-)" Ca+Kr /e0 SrF. 2c)o - P/¢,�O /[LION Nf (yY0 <br />30L REGI <br />320. DATE FILED BY REGISTRAR AAa. Dry. riJ <br />FEB 2 i "a <br />41 <br />This certifies this document to be a true copy of an original record on file with Vital <br />Statistics, Douglas County Health Department, Omaha, Nebraska. Certified copies must have <br />a raised seal in the area to the left. Reproductions of this green certificate are not <br />legal copies. A.;.e <br />Nate issued: FEB 2 5 199E 1lyistrar3 F' • M' P. N6 <br />Return to: Respeliers & Harmon, P.C. , P.O. Box 4519, Omaha, Nebraska 68104 <br />