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<br />I Register of Deeds of Hall County, Nebraska
<br />Please record this document together with the attached Certificate of Death against the following real estate:
<br />A tract of land comprising a part of the Southwest Quarter of the Northwest Quarter (SW' /4NWY4) and a art of the Northwest Quarter the Southwest Quarter
<br />(SW' /.SW' /;), all in Section Thirty Five (35), Township Eleven (11) North, Range Ten (10), West of the 6 P.M., in Hall County, Nebraska, more particularly
<br />described as follows: Beginning at the Southwest corner of said NW% thence Northerly along the West line of said NW' /., a distance 1,318.73 feet to the
<br />Northwest corner of said SW' /4NW' /4; thence Easterly along the North line of said SW' /,NW' /4, a distance of 1,290.0 feet; thence Southerly parallel to the West
<br />line of said NW' /4, a distance of 1,350.7 feet; thence Westerly parallel to the North line of said SW' /4NW' /., a distance of 1,290.32 feet to the West line of said
<br />SW' /4; thence Northerly along the West line of said SW' /4, a distance of 31.97 feet to the place of beginning.
<br />WHEN THIS QOPYCA $ THE RAj$fiD SEAL OF THj1 NEBRASKA H�AL�'W ",iA'Jdl���l $,/�t�(l��S
<br />SYSTEA4 it C ERTIRES THE 8E40 YIR TO "BE A TRUE COPY 0 I THE OR1;G1 A e ns 'ON ! w1TW
<br />THE NEBRASKA HEALTH AND HUMAN SP'RWICES SySTgM, WTALz
<br />1M.s
<br />THE LEGAI, DEPOSITORY FOR WrAL REGURD&
<br />DATE OF ISSUANCE k
<br />1/11/2005
<br />�a��I/Ir.
<br />200507620
<br />5 �asslsT .NT��AT_�1�EOlT1�4
<br />LINCOLN, NEBRASKA HEALTH ANDWL1MAN rSEP", , �;r I NBrG�l1
<br />STATE of NEBRASKA- DEPARTMegT of HEALTH AND HUMAYSERVICES .' ; S�i"Jj�YOXtT
<br />VITAL STATISTICS � V 4 14076
<br />CERTIFICATE OF DEATH-! :
<br />[lDFCE.NCNT -NAME FIRST MIDDLE LAST 2. fiEX 3:• DATE OF DEAYW ' /Month pa Year/
<br />el le December 2004
<br />Y D STATE OF BIRTH a ingtin U.S.A., ame country/ 5a. AGE - Last Binhday UNDER 1 YEAR UNDER 1 D V 9, pA E OF: BIRTW' dMOnlh. Day. Year /
<br />B e 1- u. s , Nebraska IYrs.l 4 5b. M05, l 'D YS 5c. OURS' MINS
<br />A -4 '11 16 1920
<br />'Y. SOCIAL SECURTIV NUMBER Ba. PLACE OF DEATH
<br />HOSPITAL; Inpatient OTHER; Nursing Home
<br />508- 12 -159i - ❑ •...� --
<br />eb.FACILITY -Name ( Itnoonsa tytion,Vivesiraetandr,ymbar) ❑ ER Outpatient ❑ Raemepoe
<br />St. Francis Medica ❑ ODA ❑ Other ISpac N,
<br />ec. CITY. TOWN OR LOCATION OF pEATH ed. INSIjhTY ITS Be. COUNTY OF DEATH
<br />Grand Island Yee ❑ all
<br />9a. RESIDENCE • STATE 9b. COUNTY ,9C CITY, TOWN OR L .9d. STREET, AND NUMBER /including Zi Cpde1 9e. INSIDE CITY LIMITS
<br />Nebraska Hall r an Yes Nor ❑
<br />10. : RACE • (e.g., White. Black, American Indian. 11. ANCESTRY Ig.g tlallen, Mexican German; e,tcl, ❑ MARRIED © WIDOWED 1 NAME OF SPOUSE tit wile. give maiden name)
<br />e.�iq/.! ISp�ecltgle
<br />(specify) German NEV FR DIVORCEq...
<br />A
<br />14a. USUAL OCCUPATION /Give kindot work done during most 14b. KIND OF BUSINESS I 15. EDUCATION (Speml only ni hest grade completed/
<br />of working fits, even it retired)
<br />Elementary or Secondary 10 -121 College It -4 or 5'I
<br />Medical Rece 1 ionisi oc o " i
<br />1S. FATHER - NAME FIRST MIDDLE LA ST 17 Mp7HER FIRST MIDDLE MAIDEN SURNAME
<br />Hear W. Kaisex Ana Knoe f 1
<br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? Ibe, INFORMANT -NAME
<br />(Yas. no, or unk.l I (if yes. 9,va war and dares of'gahrices)
<br />N De nis Harb
<br />19b. INFORMANT MAILING ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP)
<br />420 S. Grant Street Gr=ZIP) d Ne raska 68803 - 4
<br />70EMMBA�NA METHOD DISPOSITION 27 b. DATE 21c, CEME7ERV OR CREMATORY NOME
<br />Boazd
<br />1085 Burial val Dec 17. , 2004 Nebraska Anatomical
<br />22a. FUNERAL HOME NAME 21d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
<br />Nebraska Anatomical Board rn
<br />Omaha ebr
<br />22b. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO., CITY OR TOWN, STATE, ZIP)
<br />986395 Nebraska Medical Center Omaha Nebraska 68198 ;6395
<br />23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lal. Ib), AND fcl) I Inlarvel bet Ben onset and death
<br />PART
<br />(a) Ch iVl D9 /L V (dI J �/-
<br />D E•TO, OR AS A CQNSEOUENCE OF: Into,al betwig6n anger and tlealh
<br />49 /171
<br />OUE 10, OR AS A CONS OUENC F: Interval between onset and death
<br />(Cl I
<br />OTHER SIGNIFICANT CONDITIO - Condilions conlrlbuling to the elh but npl releted PART III IF FEMALE, WAS THERE A 24 AUTOPSY 25. WAS CASE REFERRED TO MEDICAL
<br />PART
<br />yy PREGNANCY IN PAST 3 MONTH57
<br />II Cr r /1 d,/j', , EXAMINER OR CORONER?
<br />(f �jr (Ages 10 -54) Yes No Yes No Yet, No
<br />26a. 286. DATE OF INJURY /Mp..'Day. Yr. 28c: HOUR OF INJURY 28d. DESCRIBE HOW INJJRV DCCURRED
<br />i� Accident ❑ Undetermined M
<br />Suicide Pending 28e. INJURY AT WORK 26f, oHlce hulldlny.JelaV is°;�cr�1' arm, street, factory 269, LOCATION STREET OR R.F,D. NO. CITY OR TOWN STATE
<br />Homicide Investigation Yes ❑ No ❑
<br />27a. DAYS OF DEATIHqH lMo.. Day. Yr) " 28a.`DATE SIGNED (Mo.. Day. ,Yr.) 28b. TIME OF DEATH
<br />fl; 271). DATE SIGNED (Mo.. pay. Yr.) 277. TIME OF DEATH } 280. PRONOUNCED DEAD /Mo.. pay. Yrl 28d. PRONOUNCED DEAD /rfpurl
<br />E o �Z ���(� 0/3ca M N` M
<br />27d, To the East of My . knowledge, death oceurrod at Ih e. date
<br />place and due to the a 288. On the bests of examination end,or inveskgaaon, in my opinion death occurred a1
<br />causes) slated. 'lJn x the time, date and place and dye to the cause(s) Stated.
<br />Si nature and Title)F�J Si nature no Title) 29. DIO TOBACCO USE CONTRIBUTE TO THE pEATH7 3 HAS ORGAN OR TISSUE pONA710N BEEN CpN51pEREC7 30.6 WAS BONSENT GRANTED?
<br />❑ YES ® NO ❑ UNKNOWN ❑ YES NO ❑ YES NO
<br />31. NAME AND ADDRESS OF CERTIFIER HY3ICIAN, CORpNE ��SICV+N Oq COU�' � pgNEy) /type or Pri"`nf /YYY�
<br />L> CA, P z �Ycv- z0h,
<br />32a. REG157- AR V 32b. DATE FILED BY REGISTRAR /M0.. pay. Yr.)
<br />_... ncr+ to Try )nnA
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