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<br />DECEDENT - NAME FIRST MIDDLE LAST
<br />M h i '�
<br />3 DATE OF DEATH /Month Day Ye7rl
<br />Cornell Stewart Sober
<br />V `
<br />C M Cr
<br />Z n�
<br />4 CITY AND STATE OF BIRTH ill not rn USA name country)
<br />5a. AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />N
<br />16 . DATE OF BIRTH /Mont. Day. Year/
<br />Shelton, Nebraska
<br />(Yrs)
<br />85
<br />August 14, 1915
<br />Sb MOS ! DAYS
<br />5c HOURS MINIS
<br />7 SOCIAL SECURTIY NUMBER
<br />7C i M\ r
<br />m
<br />Qn
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home
<br />c, N
<br />8b FACILITY - Name (It not,nslaution, give street and number/
<br />Good Samaritan Hospital
<br />❑ DOA ❑ Other,3oec,tyt _-
<br />8,. CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS Be COUNTY OF DEATH
<br />Kearney 0 ❑ Buffalo
<br />Yea No
<br />9a. RESIDENCE - STATE
<br />0
<br />r*3
<br />9c CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER pncluding Zip code,
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />. Adams
<br />Kenesaw
<br />15224 S. 190th RD
<br />❑
<br />Yes No
<br />10 RACE - (e.g., White. Black. American Indoin-1
<br />11. ANCESTRY le.g.. Italian. Mexican, German, etcl
<br />Cn
<br />t3 NAME OF SPOUSE ill wife give maiden name)
<br />etc llSoe, bite
<br />W
<br />ISpeclyl American
<br />NEVER DIVORCED
<br />MARRIED
<br />Phyllis Johnson
<br />'USUAL OCCUPATION /Gwe kind of work done during most 14b
<br />KIND OF BUSINESS INDUSTRY
<br />WHEN THIS COPY CARRES THE RAISED SEAL OF THE NEBRASKA HEAL TH. AMAHIIMAN SERVICES
<br />d workmp.yl�e, �e�ven elr/ , l%1 afesman
<br />Automotive
<br />Elementary or 9`12idary (0 -12) College 11 -4 or 5.1
<br />SYSTEM, R CERTIFIES THE BELOW TO BE A TRUE COPY OF THE OR/GI =W MFILE WITH
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Clyde Sober
<br />Myrtie Griffin
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST*ft.T mod; HINICH IS
<br />19a. WFORMANT -NAME
<br />es no or unk.1 III yes 9— war and dates of serviced
<br />Phyllis Sober
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />191, INFORMANT MAILING ADDRESS (STREET OR R D NO.. CITY OR TOWN. STATE. ZIP!
<br />15224 S. 190th RD Shelton, NE 68876
<br />DATE OF ISSUANCE
<br />200309580 COOPER
<br />21. METHODOF DISPOSITION
<br />21b. DATE 21c
<br />CEMETERY OR CREMATORY NAME
<br />_ ILL rS.
<br />OCT 16 2000 A�SISTA7VT STATERE�IS77iAR
<br />❑ Burial ❑ Removal
<br />10/3/00
<br />Nebr. Anatomical Board
<br />LINCOLN, NEBRASKA HEALTH AND-HUNAN SERVICES S1fTEM
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funeral Home
<br />❑ Cremation ® Donation
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND kUkkN VICES FNARCEAD SUPPORT
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN, STATE, ZIP)
<br />P.O. Box 126 Wood River, NE 68883
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR IaI. rot. AND (c)l I Interval between onset and death
<br />VITAL STATISTICS - ` -
<br />CERTIFICATE OF DEATii �-' = _� ^
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<br />DECEDENT - NAME FIRST MIDDLE LAST
<br />2 SEX
<br />3 DATE OF DEATH /Month Day Ye7rl
<br />Cornell Stewart Sober
<br />Male'
<br />October 3, 2000
<br />4 CITY AND STATE OF BIRTH ill not rn USA name country)
<br />5a. AGE - Last Birthday I
<br />UNDER 1 YEAR
<br />UNDER I DAY
<br />16 . DATE OF BIRTH /Mont. Day. Year/
<br />Shelton, Nebraska
<br />(Yrs)
<br />85
<br />August 14, 1915
<br />Sb MOS ! DAYS
<br />5c HOURS MINIS
<br />7 SOCIAL SECURTIY NUMBER
<br />Ba PLACE OF DEATH
<br />712 -05 -4415
<br />HOSPITAL ® Inpatient OTHER ❑ Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />8b FACILITY - Name (It not,nslaution, give street and number/
<br />Good Samaritan Hospital
<br />❑ DOA ❑ Other,3oec,tyt _-
<br />8,. CITY TOWN OR LOCATION OF DEATH 8d INSIDE CITY LIMITS Be COUNTY OF DEATH
<br />Kearney 0 ❑ Buffalo
<br />Yea No
<br />9a. RESIDENCE - STATE
<br />gb COUNTY
<br />9c CITY. TOWN OR LOCATION
<br />9d. STREET AND NUMBER pncluding Zip code,
<br />9e INSIDE CITY LIMITS
<br />Nebraska
<br />. Adams
<br />Kenesaw
<br />15224 S. 190th RD
<br />❑
<br />Yes No
<br />10 RACE - (e.g., White. Black. American Indoin-1
<br />11. ANCESTRY le.g.. Italian. Mexican, German, etcl
<br />12 MARRIED ❑ WIDOWED
<br />t3 NAME OF SPOUSE ill wife give maiden name)
<br />etc llSoe, bite
<br />W
<br />ISpeclyl American
<br />NEVER DIVORCED
<br />MARRIED
<br />Phyllis Johnson
<br />'USUAL OCCUPATION /Gwe kind of work done during most 14b
<br />KIND OF BUSINESS INDUSTRY
<br />15 EDUCATION (Specify only highest grade completedl
<br />d workmp.yl�e, �e�ven elr/ , l%1 afesman
<br />Automotive
<br />Elementary or 9`12idary (0 -12) College 11 -4 or 5.1
<br />[14a
<br />ATHER - NAME FIRST MIDDLE LAST
<br />17 MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Clyde Sober
<br />Myrtie Griffin
<br />WAS DECEASED EVER IN US ARMED FORCES
<br />19a. WFORMANT -NAME
<br />es no or unk.1 III yes 9— war and dates of serviced
<br />Phyllis Sober
<br />No
<br />191, INFORMANT MAILING ADDRESS (STREET OR R D NO.. CITY OR TOWN. STATE. ZIP!
<br />15224 S. 190th RD Shelton, NE 68876
<br />20 EMBALMER - SIGNATURE 8 LICENSE NO
<br />21. METHODOF DISPOSITION
<br />21b. DATE 21c
<br />CEMETERY OR CREMATORY NAME
<br />Not embalmed
<br />❑ Burial ❑ Removal
<br />10/3/00
<br />Nebr. Anatomical Board
<br />22a. FUNERAL HOME -NAME
<br />21d CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Apfel Funeral Home
<br />❑ Cremation ® Donation
<br />�.1�t�11Q lYLr'
<br />Omaha, N
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO_ CITY OR TOWN, STATE, ZIP)
<br />P.O. Box 126 Wood River, NE 68883
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR IaI. rot. AND (c)l I Interval between onset and death
<br />PART /
<br />uxi'di'te
<br />(al
<br />DUE TO, OR AS A CONSEQUENCE OF Interval between onset and death
<br />SP)r'kTT• -j _(II L- I (LA �
<br />Ibl /_Q .r
<br />- -- _ - -- _ - - -. .— interval cetween onset and oeaw
<br />DUE TO, OR AS A CONSEQUENCE 6F i
<br />1
<br />�i �2.tJvl�L L i
<br />(cl I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related
<br />PART III IF FEMALE. WAS THERE A 24
<br />AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PART //
<br />� �
<br />PREGNANCY IN THE PAST 3 MONTHS1
<br />EXAMINER OR CORONER'
<br />l
<br />(Ages 10.541 Yes No
<br />Yes No
<br />Yes R No
<br />26a
<br />266 DATE OF INJURY IMo.. Day. Yr)
<br />25c HOUR OF INJURY I 26d. DESCRIBE HOW INJURY OCCURRED
<br />U Acc,dent r Undetermined
<br />M
<br />Sr-de f—I Pending
<br />26e INJURY AT WORK
<br />26f PLACE OF INJURY - AI home. farm. street. factory 26g. LOCATION STREET OR R F 0 NO CITY OR TOWN STATE
<br />FlHomicide investigation
<br />ves ❑
<br />❑
<br />office building, etc ISpecV
<br />j
<br />No
<br />27a DATE OF DEATH IMo Day vr)
<br />28a DATE SIGNED IMO Day Yrl
<br />28b TIME OF IJATH
<br />10/3/2000
<br />M
<br />127b. DATE SIGNED (Mr. Day vr;
<br />I
<br />27c. TIME OF DEATH
<br />$ r 28c PRONOUNCED DEAD IMo_ Day. Yrl
<br />28d. PRONOUNCED DEAD (Hour)
<br />to, f7-oo
<br />2o42 A M
<br />M
<br />27d To the best of my knowledge rrd the Ume. date and place and due to the
<br />`>28e On the basis of examination and or investigation, m my opinion death occurred at
<br />® causes) stated
<br />l
<br />0_a,
<br />,i = the time. date and place and due to the causes) stated�Si
<br />nature and T�tlel ► r V
<br />(Signature and Title) ►
<br />29 DID TOBACCO USE CONTRIBUTE T DEATH? 30.a
<br />HAS ORGAN OR TISSUE DONATION BEEN CONrCIIED j � � 30.b
<br />Cki,
<br />_
<br />WAS CONSENT GRANTED'!
<br />; I VES ❑ NO ❑ UNKNOWN
<br />N YES ❑ NO
<br />YES n NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. CORONERS PHYSICIAN OR COUNTY ATTORNEY( 'Type o, P-P
<br />L.I. Mansur, MD 3321jAvenuejA Kearney, NE 68847
<br />32a. REGISTRAR
<br />32b DATE FILED BY REGISTRAR /Mo.. Day. Yr, ,
<br />OCT 13 2000
<br />I
<br />m
<br />A portion of Lot (7) and a portion of Lot (8), in Section 30, Township 9 North, Range 12, Hall County, Nebraska, consisting of about 18
<br />acres, more particularly described as follows: Commencing at the Northeast corner of Section 31, hereby known as point of beginning_
<br />thence west 1467 feet; thence north 395 feet, thence west 66 feet, thence north 208 feet, thence east 1533 feet along the shoreline to a point
<br />about 440 feet north of the point of beginning, thence south to the point of beginning. This is not to include any properties of Lot (15).
<br />
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