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Evidence ®f Insurance far Mortgagee/Other
FARMERS
Interests INSURANCE
This form is not the contract of insurance. It is a memorandum of coverage limited to mortgagee/other interests, provided at their
request and applicable to the dwelling or building at the location below. The provisions of the policy will prevail in all respects. This
certificate of insurance does not affirmatively or negatively amend, extend, or alter the coverage afforded by the insurance policy.
Should the insurance policy be cancelled by the company before the expiration date thereof, notice will beg iven in accordance with the
policy provisions.
Policy Number:
78171-41-40
Policy Type:
Farmers Flexs' Personal Home
Policystatus:
In Force
Term Effective:
12/4/2023 12:01 AM
Renewal Date:
12/4/2024 12:01 AM
Insured:
Keith Matzen
Kathy Matzen
1415 Park St
Blair, NE68008-1626
PropertyAddress
1415 Park St, Blair, NE68008-1626
Underwritten By: Fire Insurance Exchange
6301 Owensmouth Ave.
Woodland Hills, CA91367
Your Farmers Mickey Manley II Agency Inc
Agent: 12111 Anne St
Omaha, N E 68137-2007
(402)391-1656
FAX: (402) 934-5900
mmanleyl @farmersagent.com
Coverage
Limit
Coverage
Limit
Coverage A - Dwelling
$208,000
Coverage B - Separate Structures
$20,800
Extended Replacement Cost
10%
Coverage D - Loss of Use
$41,600
(In Addition to Coverage A Limit)
($20,800)
Additional Living Expense Term
12 Months
Coverage C - Personal Property
$114,400
Coverage F - Medical Payments To Others
$1,000
Personal Property Replacement Cost
Covered
- - -
Cyber and Identity Shield
Not Covered
Coverage E - Personal Liability
$300,000
- - - -
Water Backup and Sump Overflow
Not Covered
Personal Injury
Not Covered
HOA Loss Payment
$1,500
Limited Matching Coverage for Siding and Roof
Not Covered
Materials
Building Ordinance or Law
(10% of Coverage A or B)
Coverage A
$20,800
Coverage B
$2,080
Roof Materials Loss Settlement
Replacement
Cost
Type of Loss
Liability Losses
farmers.com
Deductible
$0
25-8975 9-13 Page 1 of 3
Applicable tneach covered loss except Wind o/Hail Loss
Wind and Hail Deductible (3%ofCov AUmit)
Single Loss Deductible
Percent Deductibles adjust with changes to Cov. A Limit
fannem.com
$500
$6,240
Covered
/soms 9-13 Page ovfa
Mortgagees and Other Interests
1st Mortgagee Loan Number
Omaha Federal Credit Union Not Applicable
3001 S 82nd Ave
Omaha, NE 68124-3207
Annual Premium:
$3,288.00
Fees:
$25.00
Total Premium:
$3,313.00
Balance Due:
On Scheduled Pay Plan
Who Pays: Insured
� .r••. Rom• • - •
Effective Date 2nd Mortgagee
12/4/2023 Not Applicable
Payment Remittance Address
Payment Processing PO Box 0991
Center: Carol Stream, IL 60132-0991
The following provision applies only if a mortgagee is named in the Declarations, and the mortgagee has foreclosed on the property
prior to the date of loss:
The applicable deductible for any interest of any mortgagee will be the smallest of the following amounts:
(1) the deductible stated in the Declarations; or
(2) $1,000.
This provision does not apply to loss or damage from earthquake (if covered) or hurricane, where a separate, increased deductible
applies to loss or damage caused by that peril.
farmers.com
25-8975 9-13 Page 3 of 3
Evidence of Insurance for Mort ag ee/Other rvl�
g FARMERS
Interests INSURANCE
This form is not the contract of insurance. It is a memorandum of coverage limited to mortgagee/other interests, provided at their
request and applicable to the dwelling or building at the location below. The provisions of the policy will prevail in all respects. This
certificate of insurance does not affirmatively or negatively amend, extend, or alter the coverage afforded by the insurance policy.
Should the insurance policy be cancelled by the company before the expiration date thereof, notice will be given in accordance with the
policy provisions.
Policy Number:
30098-01-60
Policy Type:
Farmers Smart Plan Home°
Policy Status:
In Force
Term Effective:
12/4/2022 12:01 AM
Renewal Date:
12/4/2023 12:01 AM
Insured:
Keith Matzen and Kathy Matzen
Coverage E - Personal Liability
1415 Park St
Identity Fraud Expense Coverage
Blair, NE 68008-1626
Your Insured Property
Property Address
1415 Park St, Blair, NE 68008-1626
Coverage
Limit
Coverage A- Dwelling
$197,000
Extended Replacement Cost
10%
(In Addition to Coverage A Limit)
($19,700)
Coverage C - Personal Property
$108,350
Contents Replacement Coverage
Covered
Coverage E - Personal Liability
$300,000
Identity Fraud Expense Coverage
Not Covered
Limited Matching Coverage for Siding and Roof
Not Covered
Materials
Deductible
Type of Loss
Applicable to each covered loss except Windstorm/Hail Loss
Windstorm/Hail Loss (3% ofCov. A Limit)
farmers.com
25-8975 9-13
Underwritten By: Farmers Insurance Exchange
6301 Owensmouth Ave.
Woodland Hills, CA 91367
Your Farmers Mickey C Manley II
Agent: 12111 Anne St
Omaha, NE 68137-2007
(402) 391-1656
FAX: (402) 934-5900
mmanleyl @farmersagent.com
Coverage
Limit
Coverage B - Separate Structures
$19,700
Coverage D - Loss of Use
$39,400
Coverage F - Medical Payments to Others
$1,000
Building Ordinance or Law
(10% of Coverage A or B)
Coverage A
$19,700
Coverage B
$1,970
Roof Materials Loss Settlement Replacement
Cost Value
Deductible
$500
$5,910
Page 1 of 3
Evidence of Insurance for Mortgagee/Other Interests (continued)
Percent Deductibles adjust with changes to Cov. A Limit
farmers.com
25-8975 9-13 Page 2 of 3
'III y U
Date of Vaccinat' n: 06-14-23
Next Vaccinatio on: 06-13-26
VETERINARY CLINIC
Pet Vaccination Clinic
2911 S. 120th St.
Omaha, NE 68144
402-480-3393
Certificate No. 35358
Previous Vaccination: 202058
OWNER OF ANIMAL
Kitty Matzen
1415 Parks St
Blair, NE 68008
(402) 278-2129
This is to certify...
THAT 1 HAVE VACCINATED THE ANIMAL DESCRIBED
BELOW AGAINST RABIES.
Patient information...
PATIENT: Princess
TAG NO:
236632
SPECIES: Canine
BREED:
Shih Tzu Mix
SEX: Spayed Female �
AGE:
10 years
WEIGHT: 0.00 lbs
COLOR:
White and Black
MICROCHIP:
MFG BY: ZOETI, SERIAL:,58438 , E IRES: 09/05/23, ADMIN: SQ
Signed:
Monte Pauli, DVM Lic2hse 614
Other Vaccinations...
Date of Vaccinatio , 06-14-23
a 1;23
Next Vaccination (on: f06 -13 -
VETERINARY CLINIC
Pet Vaccination Clinic
2911 S. 120th St.
Omaha, NE 68144
402-480-3393
Certificate No. 36369
Previous Vaccination: 202059
OWNER OF ANIMAL
Kitty Matzen
1415 Parks St
Blair, NE 68008
(402) 278-21219
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW AGAINST RABIES.
Patient information...
PATIENT: Kingston
TAG NO:
236633
SPECIES: Canine
BREED:
Shih Tzu Mix
SEX: Neutered Male
AGE:
9 years
WEIGHT: 0.00 lbs
COLOR:
White and Tan
MICROCHIP:
MFG BY: ZOFTI, SERIAL: 584384,
EXP :09/05/23,
ADMIN: SQ
Signed:
'fA14"
,Monte"auli, DVM, License:
Other Vaccinations...
Evidence of Insurance for Mortgagee/Other Interests (continued)
..-• . •. .
1st Mortgagee Loan Number Effective Date 2nd Mortgagee
Omaha Federal Credit UnionNot Applicable 1/11/2017 Not Applicable
3001 S 82nd Ave
Omaha, NE 68124-3207
NMI I M r, TIM M11
Annual Premium;
Fees:
Total Premium:
Balance Due:
Who Pays:
$2,846.93
$0.00
$2,846.93
On Scheduled Pay Plan
Insured
Payment Remittance Address
Payment Processing PO Box 0991
Center: Carol Stream, IL 60132-0991
The following provision applies only if a mortgagee is named in the Declarations, and the mortgagee has foreclosed on the property
prior to the date of loss:
The applicable deductible for any interest of any mortgagee will be the smallest of the following amounts:
(1) the deductible stated in the Declarations; or
(2) $1,000.
This provision does not apply to loss or damage from earthquake (if covered) or hurricane, where a separate, increased deductible
applies to loss or damage caused by that peril,
Authorized Representative
farmers.corn
4/4/2023
Date
25-8975 9-13
Page 3 of 3
Thursday, July 01, 2021 01;32 PM Farmer's Insurance 4029345900 p 01
To:
Fax; 4024264195
Phone;
RE:
❑ Urgent
❑ Far Revlew
Comments:
From:
Date: 7/1/2QZ1
❑ Please Comment
❑ Please Reply
T� wham it may concern, Farmers policies cover all breeds. With their umbrella they have $1,30p,000 worth of
coverage for thls.
fax cover
[Khans number - ]
[Fax number - ]
[e-mail - ]
[Webslte - ]
Farmer's Insurance 4029345900 p 02
Evidence of Insurance for Mortgagee/ether
Interests
FARMER
INSURANCE
This farm is earths r..oniract of insurance. It is a mernnrand�.rm ofcoverage limited to martgegee/ether imerests, p+ovided at their
i-erluest and applir..able to the dwelling ar h�.�llciing at the lacatinn below. The pravisinnsnf
the policy will prevail in all respects. This
certificate of insurance does eat affirmatively or negatively amend, extend, ar alter thecnverage
afforded bythe insurance r7rslicy.
Should the insurance policy he cancelled by the company hefnre the ex.piratinn date thereof, nnticevJill he given in accordance viikh the
pnliGy provisions.
PrsJi'tyNumk}ar: 30098-01-60 U11d8rWYlttBf3 Hy:
Farr'r7ers Il�surdl�c.e Eucharl�e
PolrcyType; Farr�r7ersSrnartPldnHomey
6301 ❑wensntioutl7Ave.
PolrcyStatus: In Foree
Vlloorllani� Hills, CA�J13G7
Tern�Effectrve; 12/4/2424 12;01 AM Your Farmers
MiikeyCMdrdeyll
Renewal orr[e; 12/4I2�21 12;01 AM Agent:
1211 1 Ar1r`le SC
Insured; Keitl�i Matzen ar��J KathyMataeil
Orriakra, NEG8137-2447
1415 ParkSt
(402) 391-165G
Blair, NE 68408-1426
FAX'. (402) 934-5900
mmanleyl r�Farmersagent.com
Your rr�sur�d Prop�r#y
Pro perry Address
1415 Park5t, Blair, NE68008-1525
Coverpges
Coverage
Llmlt
Coverage
Llmit
CuverageA-Dvrelliny
;1GF�,00p
CoverageB-5eparata5tructures
�1G,6g0
Extendeii Replacement Cost
14°�
Coverage D - Loss of Use
$�3,200
(In Adcliti+into Coverage A Limit)
(�16,G00)
Coverage F - Medical Payments to Others
$1,000
Cv�aerage C-Personal Property
$91,30r7
Cc,r,ter7ts Rek7lacerr�er�+t Cu��ereye
Covered
Building Ordindrlce or Law
(10`/� of Cgverage A or- B)
Coverage E-Personal Liability
$3QQ,000
C4`,ar.ag� A
$16,60U
Identity Fraud Expenset�overage
Not�avered
�o��eragee
$1,F;,��
Llrr}ited�/IatehingCaveragefar5idingandRaaf
NotCavered
ftaafMaterialsLassSettlernent
Replacement
Materials
Cast Value
DeduG#ibl�
TyNe n f Lass
Ai.>plirableto?ar..h rnvered Inssexcept Wincl�torrn/Hail Loss
Windstoi m/Hail Loss (3%� ofCov, A Limit)
Percent Qeducti�les arijust •with changes to Cov, A Li���it
farrners.c�m
Deal uctililP
$50s)
$4,980
2r$$75 9.13 Page 1 of 2
Farmer's Insurance 4029345900
p 03
E'vidanca of Insurance for Mortga�ea/O#her In#4rQs#s (continued)
Mortgagees and Other Interests
f st Martga{�ee Loan Number
Omaha Federal Credit iJriion NotApplicable
3D01 S 82nd Ave
Omaha, NEF8124-32Cf7
Premium detp!!�
Arrr�uar Premium: $2,836.2b
Fees: $0,00
Tutc�f Premirrrn; $2,i33�.2G
8ukurc��cre; Or,.�cheduledP2yPl2r,
Who Pays: Insured
EffectJvel?are 2ndMartgagee
1J11/�Q17 NntA�snlir..able
Payment l�emittartice Address
Payment Praeessing PO Box D99 I
Center: Carol 5trea�l�, I L 60132-0991
Mortgagee Qeductible Olause
Thee fallowing prevision applies only if2 r7iortgagee is named in the Declarations, and the r7kartgagee has foreclosed on tl7e property
prior to the date of lass:
The applicable �leduatiki,le for any interest of any murtyagee will be the smallest ufthe following amounts;
(1) tl�e decluctil�le stated in tl��e Declarations; ur
Th is provision class not apply to lass or damag e from earthquake (ifcavered) or h urricane, where a seFrarate, increased dedl�etible
applies to loss or damage cakased bythat peril,
�J��
Aiakh�rlFed RePresentatl�e
farrners.cam
7/1I2D21
Ra#e
tr8975 }13
Page 2 of 2
;_ ,,
_ .: . - -
��„C.ERT`IFiCA.T°E O=F �/AC.CI.N,AT.1OaV _-
Date of Vaccination: 03-05-20
Certificate No. 13513
Next Vaccination on: 03-05-23
Previous Vaccination:
VETERINARY CLINIC
OWNER OF ANIMAL
Pet Vaccination Clinic
Kitty Matzen
2911 S. 120th St.
1415 Parks St
Omaha, NE 68144
Blair, NE 68008
402-480-3393
(402) 278-2129
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW AGAINST RABIES.
Patient information...
PATIENT: Princess �� '���
SPECIES: Canine �
TAG NO: 202058
BREED: Shih Tzu Mix
SEX: Spayed Female
AGE: 7 years
WEIGHT: D.00 Ibs
COLOR: White and Black
MICROGHIP:
MFG BY: ZOETI, SERIAL: 347471, EXPIRES: 07/�/20, ADMIN: SQ
Signed:
raback, DVM �' License: 3094
Other Vacc$-nations...
;. ,.
' �..GERTjI.FICAT.E ..O,F VACCINATION `- `"
Date of Vaccination: 03-05-20
Certificate No. 13514
Next Vaccination on: 03-05-23
Previous:Vaccination:�:
VETERINARY CLINIC
OWNER OF ANIMAL
Pet Vaccination Clinic
Kitty Matzen
2911 S. 120th St.
1415 Parks St
Omaha, NE 68144
Blair, NE 68008
402-480-3393
(402) 278-2129
This is to certify...
THAT I NAVE VACCINATED THE ANIMAL DESCRIBED BELOW AGAINST RABIES.
Patient information...
PATIENT: Kingston r� (, /� �
�'`"
TAG NO: 202059
SPECIES: Canine U � ��'f
BREED: Shih Tzu Mix
SEX: Neutered Male ��
AGE: 6 years
WEIGHT: 0.00 Ibs
COLOR: White and Tan
MICROCHIP:
MFG BY: ZOE�TI, S;�RI L: 347471, EXPI�2ES: 07/28/20, ADIVIIN;
SQ _
J Y� 3p�
� :'�" ���
Signed: +� ���>/ �.`�, �"--�,a, �r'l!�'x�.,� �
��,uli� Roraback, �9 VM � License:
Other Vacihations...
Thursday, July 01, 2021 01;32 PM Farmer's Insurance 4029345900 p 01
To:
Fax; 4024264195
Phone;
RE:
❑ Urgent
❑ Far Revlew
Comments:
From:
Date: 7/1/2QZ1
❑ Please Comment
❑ Please Reply
T� wham it may concern, Farmers policies cover all breeds. With their umbrella they have $1,30p,000 worth of
coverage for thls.
fax cover
[Khans number - ]
[Fax number - ]
[e-mail - ]
[Webslte - ]
Farmer's Insurance 4029345900 p 02
Evidence of Insurance for Mortgagee/ether
Interests
FARMER
INSURANCE
This farm is earths r..oniract of insurance. It is a mernnrand�.rm ofcoverage limited to martgegee/ether imerests, p+ovided at their
i-erluest and applir..able to the dwelling ar h�.�llciing at the lacatinn below. The pravisinnsnf
the policy will prevail in all respects. This
certificate of insurance does eat affirmatively or negatively amend, extend, ar alter thecnverage
afforded bythe insurance r7rslicy.
Should the insurance policy he cancelled by the company hefnre the ex.piratinn date thereof, nnticevJill he given in accordance viikh the
pnliGy provisions.
PrsJi'tyNumk}ar: 30098-01-60 U11d8rWYlttBf3 Hy:
Farr'r7ers Il�surdl�c.e Eucharl�e
PolrcyType; Farr�r7ersSrnartPldnHomey
6301 ❑wensntioutl7Ave.
PolrcyStatus: In Foree
Vlloorllani� Hills, CA�J13G7
Tern�Effectrve; 12/4/2424 12;01 AM Your Farmers
MiikeyCMdrdeyll
Renewal orr[e; 12/4I2�21 12;01 AM Agent:
1211 1 Ar1r`le SC
Insured; Keitl�i Matzen ar��J KathyMataeil
Orriakra, NEG8137-2447
1415 ParkSt
(402) 391-165G
Blair, NE 68408-1426
FAX'. (402) 934-5900
mmanleyl r�Farmersagent.com
Your rr�sur�d Prop�r#y
Pro perry Address
1415 Park5t, Blair, NE68008-1525
Coverpges
Coverage
Llmlt
Coverage
Llmit
CuverageA-Dvrelliny
;1GF�,00p
CoverageB-5eparata5tructures
�1G,6g0
Extendeii Replacement Cost
14°�
Coverage D - Loss of Use
$�3,200
(In Adcliti+into Coverage A Limit)
(�16,G00)
Coverage F - Medical Payments to Others
$1,000
Cv�aerage C-Personal Property
$91,30r7
Cc,r,ter7ts Rek7lacerr�er�+t Cu��ereye
Covered
Building Ordindrlce or Law
(10`/� of Cgverage A or- B)
Coverage E-Personal Liability
$3QQ,000
C4`,ar.ag� A
$16,60U
Identity Fraud Expenset�overage
Not�avered
�o��eragee
$1,F;,��
Llrr}ited�/IatehingCaveragefar5idingandRaaf
NotCavered
ftaafMaterialsLassSettlernent
Replacement
Materials
Cast Value
DeduG#ibl�
TyNe n f Lass
Ai.>plirableto?ar..h rnvered Inssexcept Wincl�torrn/Hail Loss
Windstoi m/Hail Loss (3%� ofCov, A Limit)
Percent Qeducti�les arijust •with changes to Cov, A Li���it
farrners.c�m
Deal uctililP
$50s)
$4,980
2r$$75 9.13 Page 1 of 2
Farmer's Insurance 4029345900
p 03
E'vidanca of Insurance for Mortga�ea/O#her In#4rQs#s (continued)
Mortgagees and Other Interests
f st Martga{�ee Loan Number
Omaha Federal Credit iJriion NotApplicable
3D01 S 82nd Ave
Omaha, NEF8124-32Cf7
Premium detp!!�
Arrr�uar Premium: $2,836.2b
Fees: $0,00
Tutc�f Premirrrn; $2,i33�.2G
8ukurc��cre; Or,.�cheduledP2yPl2r,
Who Pays: Insured
EffectJvel?are 2ndMartgagee
1J11/�Q17 NntA�snlir..able
Payment l�emittartice Address
Payment Praeessing PO Box D99 I
Center: Carol 5trea�l�, I L 60132-0991
Mortgagee Qeductible Olause
Thee fallowing prevision applies only if2 r7iortgagee is named in the Declarations, and the r7kartgagee has foreclosed on tl7e property
prior to the date of lass:
The applicable �leduatiki,le for any interest of any murtyagee will be the smallest ufthe following amounts;
(1) tl�e decluctil�le stated in tl��e Declarations; ur
Th is provision class not apply to lass or damag e from earthquake (ifcavered) or h urricane, where a seFrarate, increased dedl�etible
applies to loss or damage cakased bythat peril,
�J��
Aiakh�rlFed RePresentatl�e
farrners.cam
7/1I2D21
Ra#e
tr8975 }13
Page 2 of 2
.�' .
�- ..
C�ERT.IFICATE.:OF �U"ACC'INATI.ON
Date of Vaccination: 03-05-20
Certificate No. 13514
Next Vaccination on: 03-05-23
Previous: Vaccination:.
VETERINARY CLINIC
OWNER OF ANIMAL
Pet Vaccination Clinic
Kitty Matzen
2911 S. 120th St.
1415 Parks St
Omaha, NE 68144
Blair, NE 68008
402-480-3393
(402) 278-2129
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW
AGAINST RABIES.
Patient information...
PATIENT: Kingston '`� ( „� '� �'
� �'�
TAG NO: 202059
SPECIES: Canine �
BREED: Shih Tzu Mix
SEX: Neutered Male `�"
AGE: 6 years
WEIGHT: 0.00 Ibs
COLOR: White and Tan
MICROCHIP:
MFG BY: ZOETI, S,�RI�L:_347471, EXPI�ES: 07/28/20, /ADMIN; SQ
tt �i�'`�"a I
Signed:
lid Roraback, f�VM License:
Other Val �hations...
®maha Pet Vaccination Clinic
2911 S. 120th St.
Omaha, NE 68144
402-443-2006
OMAHA PET VACCINATION CLINIC - 84th & H -Omaha, NE (402) 443-2006
Printed: 03-05-20 at 10:34a
FOR: Kitty Matzen
1415 Parks St
Blair, NE 68008
(402) 278-2129
Date For
Qty Description
Date: 03-05-20
Folder: 0
Invoice: 17974478
Net Price
03-05-20 Kingston
1 Canine Rabies Vaccination, 3Y
24.00
03-05-20 Princess
1 Canine Rabies Vaccination, 3Y
24.00
03-05-20
Cash payment
-48.00
Old balance Charges
Payments
New balance
0.00 48.00
48.00
0.00
Reminders for: Princess
Last done
03/23 Canine Rabies Vaccination, 3 Y 03-05-20
Reminders for: Kingston
Last done
03/23 Canine Rabies Vaccination, 3 Y 03-05-20
Doctors Instructions
Canine Rabies Vaccination, 3Y
A transient local reaction may occur at the injection site following subcutaneous
administration. In rare instances, administration of vaccines will cause lethargy, fever,
and inflammatory or hypersensitivity types of reactions. If you notice any other these
reactions, consult your veterinarian as soon as possible.
Omaha Pet Vaccination Clinic
84th & H Omaha, NE
(402) 443-2006
www.OmahaPetVaccinationClinic.com
�,
_'�
,_.
��
(fi <-�;
_ ,
,;C:E R_T'`I Fri C. A T'E Q F.\/ A C C.J N A T I Q''N =
Date of Vaccination: 03-05-20
Certificate No. 13513
Next Vaccination on: 03-05-23
Previous Vaccination:
VETERINARY CLINIC
OWNER OF ANIMAL
Pet Vaccination Clinic
Kitty Matzen
2911 S. 120th St.
1415 Parks St
Omaha, NE 68144
Blair, NE 68008
402-480-3393
(402) 278-2129
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW AGAINST RABIES.
Patient information...
PATIENT: Princess ���� �`
SPECIES: Canine �
TAG NO: 202058
BREED: Shih Tzu Mix
SEX: Spayed Female
AGE: 7 years
WEIGHT: 0.00 Ibs
COLOR: White and Black
MICROCHIP:
MFG BY: ZOETI, SERIAL: 347471, E PIRES �07/2 /20, ADMIN:
� %'
,�9�
SQ
��
Signed: A � ��a � `� -
3094
J ie�Roraback, DVM' License:
Other Vacctinations...
�'�
Omaha Pet Vaccination Clinic
2911 S. 120th St.
Omaha, NE 68144
402-443-2006
OMAHA PET VACCINATION CLINIC - 84th & H -Omaha, NE (402) 443-2006
Printed: 03-05-20 at 10:34a
FOR: Kitty Matzen
1415 Parks St
Blair, NE 68008
(402) 278-2129
Date For
Qty Description
Date: 03-05-20
Folder: 0
Invoice: 17974478
Net Price
03-05-20 Kingston
1 Canine Rabies Vaccination, 3Y
24.00
03-05-20 Princess
1 Canine Rabies Vaccination, 3Y
24.00
03-05-20
Cash payment
-48.00
Old balance Charges
Payments
New balance
0.00 48.00
48.00
0.00
Reminders for: Princess
Last done
03/23 Canine Rabies Vaccination, 3 Y 03-05-20
Reminders for: Kingston
Last done
03/23 Canine Rabies Vaccination, 3 Y 03-05-20
Doctor's Instructions
Canine Rabies Vaccination, 3Y
A transient local reaction may occur at the injection site following subcutaneous
administration. In rare instances, administration of vaccines will cause lethargy, fever,
and inflammatory or hypersensitivity types of reactions. If you notice any other these
reactions, consult your veterinarian as soon as possible.
Omaha Pet Vaccination Clinic
84th & H Omaha, NE
(402) 443-2006
www.OmahaPetVaccinationClinic.com
{
CITY OF BLAIR - 2019 PET LICENSE VERIFICATION
If you live in Blair City limits and own a dogs) and/or cat(s), complete/verify this form and return with check made payable to:
City of Blair * 218 S 16th St. *Blair, NE 68008
You may legally own a combination of four (4) adult pets, but no more than three (3) adult dogs
or three (3) adult cats per residential or dwelling unit.
LICENSE RENEWALS ARE DUE: March 15, 2019 LICENSE FEES: Dog or Cat: $16.00
Owner Name: Keith &Katherine Matzen Spayed/Neutered Dog or Cat: $11.00
Owner Address: 1415 Park St Replacement Fee for Lost Tag: $5.00
Fee includes $1.25 for the Nebraska Dog and Cat
City/State/ZIP: Blair, NE 68008--0000 Operator Inspection Program
Phone #: (402) 426-1748
Drivers License #: or Date of Birth: 8/24/1996
Name: Princess
Color: Black/VI/hite
Spayed/Neutered: False
Mirochip #
Vaccination Date: 1/3/2017
Subtotal licensed pets from below:
Replacement Tags from below:
DOB: 1/1/2015 Sex: Female
Breed: Mix Breed
Potentially Dangerous: True
Duration: 3 year vaccine
Vaccine Exp: 1/3/2020
License Fee $
Replacement:
❑Y ❑N
City Tag # 1774
Total:
t�:'
CITY OF BLAIR - 2019 PET LICENSE VERIFICATION
If you live in Blair City limits and own a dogs) and/or cat(s), complete/verify this form and return with check made payable to:
City of Blair* 218 S 16th St.'� Blair, NE 68008
You may legally own a combination of four (4) adult pets, but no more than three (3) adult dogs
or three (3) adult cats per residential or dwelling unit.
LICENSE RENEWALS ARE DUE: March 15, 2019 LICENSE FEES: Dog or Cat: $16.00
Owner Name: Keith &Katherine Matzen Spayed/Neutered Dog or Cat: $11.00
Owner Address: 1415 Park St Replacement Fee for Lost Tag: $5.00
Fee includes $1.25 for the Nebraska Dog and Cat
City/State/ZIP: Blair, NE 68008--0000 Operator Inspection Program
Phone #: (402) 426-1748
Drivers License #: or Date of Birth: 8/24/1996
Name: Kingston
Color: Black/Tan
Spayed/Neutered: False
Mirochip #
Vaccination Date: 1/3/2017
Subtotal licensed pets from below:
Replacement Tags from below:
DOB: 1/1/2015 Sex: Male
Breed: Mix Breed
Potentially Dangerous: True
Duration: 3 year vaccine
Vaccine Exp: 1/3/2020
License Fee $
Replacement:
❑Y ❑N
City Tag # 1773
Total:
Wednesday, February 27, 201910;47 AM Farmer's Insurance 4029045900 - p.01
Evid�n�� c�� I n�ur�nc� ��rr Mart �g�e/t�th�r '`
}. }. � F A t� M E a�
Int�r�'�t� IN51JkAN�E
Thi.sform i.s not the contract of insurance. It is a memorandum of coverage limited to mortgagee%that interests, provided at their
request and eppfcable to the dwelling or building at the location below. The provisions of the policywill prevail in all respects. This
certificate of insurance does notaffirmativelyor negativelyamenci, extent!, or alter the coverage afforded by the insurance policy.
Should the insurance policy be cancelled l�ythe companybefore the expiration date thereof, notice will be given in accordance with the
palicyprovisions.
Poticy Number:
30098.0 7 -60
f'olrcyTy�e:
FarmersSrnartPlanHomem
Policy5tatus:
In Force
Term Effective;
12/4/2018 12:01 AM
Renewal Ltate:
12/4/2b19 12:01 AM
Insured:
Keith Matzen and Kathy Matzen
1415 Pa rk 5t
Blair, NE 6�Ob8-1 tr26
Your lnsure�d Prr�perty
PropertyAddress
1415 p3rkSt, Blair, NE �8408-162�
�nv�rages
underwritten By: Farmers Insurance Exchange
6301 Owensmouth Ave.
Woodland Hills, CA91:i67
Yo[rrFarmers MickeyCManleyll
Agent: 12111 AnneSt
(7maha, NE E8137-2007
(402) 391-1656
FAX:(402)934-5900
mmanleyl c�farmersagent.com
Coverage
1!m!t
Caveraye
1!m!t
CoveragaA-Dwelling
$154,000
Coverage8-SeparateStructures
$15,400
Extended Replacement Cost
10°�U ($15,400)
Coverage D - Loss of Use
$30,ti00
(In Addition to Covera�le A Limit)
Coverage F -Medical Payments To Others
$1,000
Coverage C -Personal Property
$84, 700
Contents Replacement Coverage
Covered
Building Ordinance or Law
(1b%of Cove rageAorB)
Covers eE-PersonalLiabili
g tY
$300000
,
CoveragaA
$15,400
Identity Fraud Expense Coverage
Not Covered
CoveragaB
$1,540
Limited Matching Coverage for Siding and
Not Covered
Roof Materials Loss Settlement
Replacement
Roof Materials
Cost Value
is@C7(i1Cf'►JS318
Deductible
Applicable to esah covered Idss except Windsstorm/Hail Loss $500
Windstorm/Hail Loss (3% ofCov. A Limit) $4,620
percent beductibles adjust with changes to Cov. A Limit
farmers.com
�5 8475 9.13 Page 1 of 2
Farmers Insurance 4029345900
p.02
Evidence of Insurance for Mortgagee/C}ther Interests t;ct7ntinue�}
Nt+Drtgagees and Other Interests
4stMorfgagee LoanNtlmber
Omaha Federal credit Union NatApplicable
3001 8 82nd Ave
4malta, NE �8124-3247
Premium Details
Annual premium: $2,b;i6.85
Fees: �o.ao
Totat Pretnirtrn: $2,036.85
Balance Dtte:
Wlao Pays: Insured
M�rrt�agee Deduct�l.�fe Clause
Effective Date 2nd Mortgagee
1/11/zd17 NotApplicable
The followirtg provision applies only if a mortgagee is named in the Declarations, and the mortgagee hasforer.losed on the proparty
prior to the date of loss:
Tha applicable deductible for any interest afanymortgagaa will ba tl7e smallest of the fallowing amounts:
(1) the deductible stated in the Declarations, or
This provision does not apply to loss ordama�e from earthquake (ifcovered) or hurricane, where a separate, increased deductible
applies to loss ar damage caused by that per1L
������
Authorized Representative
farmers,com
2/27/2419
Date
25 9975 4-13 Page 2 of 2
FluLnili� :rt���i+�� i►
lGs�tth� f%�, �It`RCi�.
June 10, 2016
To Whom It May Concern:
Kathy Matzen (p357460) attended the required "Potentially Dangerous Dog"
(Owner Responsibility) class on June 6t" and June 13t", 2016 completing the required
session.
Dawn Thrapp
Behavior Department
Nebraska Humane Society
402-444-7800 ext.2220
8929 Fort Street Omaha NE 68134 402.444.7800 Fax 402.546.1476 www.nehumanesociety.org
Brenda Wheeler
From: kathy matzen [miemie42@hotmail.com]
Sent: Tuesday, March 15, 2016 11:18 PM
To: Brenda Wheeler
Subject: Fw: spay neuter appointment
From: Terry Barrett <TBarrett@nehumanesociety.or�>
Sent: Wednesday, March 2, 201611:31 AM
To: 'miemie42@hotmail.com'
Cc: 'kittyweis@yahoo.com'
Subject: spay neuter appointment
To whom it may concern:
Kathy Matzen has an appointment at the Nebraska Humane Society Spay and Neuter Center for her pet on 04/06/16 to
have a sterilization surgery.
Terry Barrett
Clinic Director
402 905 3480
��� _ � ��
� � � ,5 .��c � s �5
3�Z��( � �� c� sn ,���,.
D,���s�- � �, n �°�' ��, cis � �,e
�\c�v -b� � �,� G�u.sS-
��
�� � ?��'
e
�, '�``��
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i
Receipt Number : R16-192300
Person Information:KITTY MATZEN
1415 PARK ST
BLAIR NE 68008
Receipt Date: April 06, 2016
PID: P465$08
Received From:KITTY MATZEN Check No: Phone: (402) 278-2604
Item: Animal ID: Name Reference No: Price: Each: Amount:
SNC DOG SPAY UNDER 50 L8 A1072669 PRINCESS $80.00 1 $80.00
SNC MICROCHIP A1072669 PRINCESS 14.02 1 $14.02
0.0700000 .98 1 $.98
Total Fees Due: $95.00
Payments: Cash: $95.00
Check:
Credit Card:
Total Payments Received: $95.00
Thank You!
Clinic Hours
OPEN Monday -Thursday 7:15 AM - 5:30 PM
CLOSED Friday, Weekends and Holidays
Clerk: ELAWREN Transaction Date: 04/06/16 Print Date: 04/06/16
i��ane s®coe�v
..,,�,.«�,�.sx.
Receipt Number : R16-192297
NEBRASKA HUMANE SOCIETY SPAY &NEUTER CENTER
8919 FORT ST
OMAHA, NE 68134
PHONE: (402) 905-3490
FAX: (402) 905-3491
www. nhsspayneuter.org
A service of the Nebraska Humane Society
Person Information:KITTY MATZEN
1415 PARK ST
BLAIR NE 68008
Received From:KITTY MATZEN
Receipt Date: April 06, 2016
PID: P465808
Check No: Phone: (402) 278-2604
Item: Animal ID: Name Reference No: Price: Each: Amount:
SNC DOG NEUTER (PUBLIC 0 A1072667 KINGSTON $75.00 1 $75.00
SNC MICROCHIP A1072667 KINGSTON 14.02 1 $14.02
0.0700000 .98 1 $.98
Total Fees Due: $90.00
Payments: Cash: $90.00
Check:
Credit Card:
Total Payments Received: $90.00
Thank You!
Clinic Hours
OPEN Monday -Thursday 7:15 AM - 5:30 PM
CLOSED Friday, Weekends and Holidays
Clerk: ELAWREN Transaction Date: 04/06/16 Print Date: 04/06/16
��
I;�� � � � -
�� n � 3
�i�f��,
CITY OF BLAfR - 2016 PET LICENSE APPLICATION °���,� �, � � , 1
If you live in Blair City limits and own a dogs) and/or cat(s), complete this form and return with check made p�ayaf�� to: �� ���j'%'
City of Blair • 218 5. i6u' St. •Blair, NE 68008 �� ����'��_ �`�`�'`�
You may legally own a combination of four (4) adult pets, but no more than three (3) adult dogs
or three (3) adult cats per residential or dwelling unit,
LICENSE RENEWALS ARE DUE: March 15.2016
Owner Name: � 1�1 �n�-,�,n �
Owner Address: ,� � 1 C.) -' 4� j�
City/State/Zip: Blair, NE 68008
Phone# ���� �� �J�,�
Drivers License # or Date of Birth �� ' �� _ ' 1 �%
LICENSE FEES: Dog or Cat: $16.00
Altered Dog or Cat: $11.00
R I cement Fee for Lost Ta • $5 00
***PLEASE READ CARERILLY***
YOU ARE REQUIRED BY LAW TO LICENSE YOUR PETS.
Failure to do so is a violation of City ordinances 6.103 and carries
a penalty of a fine up to $150.00 per pet.
PET LICENSES RENEWALS ARE DUE BY 3/15/2016. The City
shall recognize a microchip Identification number as the license number.
It shall be unlawful for any dog or cat to wear any license or other city
identification other than that Issued by the City of Blair for such dog or
cat. The City of Blair requires proof of rabies vaccination.
ep a g.
An additional State Fee of $1.25 is being collected to fund the Nebraska Dog &Cat
PET #1 �,p,-��D�og ❑Cat ❑Spayed/Neutered License Fee $ ( "`= ,
Pet Name_�_�` -u � A�e `' I'Y�c=� Sex �1�1
Color tin .�1� Breed * i?r.�tav° CI^.11��(��k?�� Rep/acement$ ** `��
Declared Dangerous or Potentially Dangerous Dog: ❑ Y ❑ N ��tx. � wj Ch ala.� �z. Pc�L��'Lc° iL %�tFf-
MICROCHIP # (If applicable) SUBTOTAL: $
RABIES VACCINATION DATE: I�-I � -I� (3 yr) (1 yr) •/ City Tag # *
PET #2_, ❑Dog ❑Cat ❑Spayed/Neutered � License Fee $ -��'y
PetName�►��lii`�S Aq�e 1 Sex
Color '�P�r'e rl _T �,�,� � 1-c- Breed * 43r r�tc� v� � L I I I is (51� � huc Rep/acement $
Declared Dangerous or Potentially Dangerous Dog: ❑ Y ❑ N ,A.�+-�-
MICROCHIP # (If applicable) SUBTOTAL: $
RABIES VACCINATION DATE: ��- I I -tom (3 yr) (1 yr) / City Tag #
PET #3 ❑Dog ❑Cat ❑Spayed/Neutered License Fee $
Pet Name Aq�e Sex
Color Breed * Rep/acement $ **
Declared Dangerous or Potentially Dangerous Dog: ❑ Y ❑ N
MICROCHIP # (If applicable) SUBTOTAL: $
RABIES VACCINATION DATE: (3 yr) (1 yr) City Tag #
*PLEASE INCLUDE THE CITY TAG NUMBER IF THIS IS A RENEWAL
** (This fee is due along with License Fee if requesting at the time of license renewal.)
Donation to care for animals: _ $1 _ $3 $5 — $10 _Other
***SEE BACK OF FORM FOR BREED SPECIFIC LICENSE REQUIREMENTS
VISA / MC #
Signature
Do Not Send Cash by Mai/ TOTAL ENCLOSED $
Expires: Security Code:
If you have questions, please contact City Hall at (402) 426-4191 or by Fax: (402) 426-4195
NEW PET/NEW RESIDENT LICENSING REQUIREMENTS(Mardli5/atefeedatenotapplicablefornewpeis/newresidents)
Newly Acquired Pets: New Residents to Blalr:
■ Must be licensed within 10 days of ownsship ■ Must register pets within 10 days of
■ <OR> at 6 months of age if puppy/Idtten residency.
7 1 �?1
i:h � ' ;",1 e�
�]� � 1 ly -_ it
r � ;�
�, .
- ��
CITY O� BLAIR - 2016 PET LICENSE APPLICATION �_,, `
If you live in Blair City limits and own a dogs) and/or cat(s), complete this form and return with check made payable to �� -% -
City of Blair • 218 S. i6t" St. •Blair, NE 68008 ` �+ �� '� -'
You may legally own a combination of four (4) adult pets, but no more than three (3) adult dogs
or three (3) adult cats per residential or dwelling unit.
LICENSE RENEW�<QALS ARE DUE: r�Msarch 15.2016
Owner Name: i`°f�JLi����i�ta � U�,�,��
Owner Address: � �T 1����
City/State/Zip: Bla� i`r, NE 68008
Phone# '��� ��l' I���
Drivers License # or Date of Birth I � ®'c� `�'
LICENSE FEES: Dog or Cat: $16.00
Altered Dog or Cat: $11.00
Replacement Fee for Lost Tag: $5.00
***PLEASE READ CAREFULLY***
YOU ARE REQUIRED BY LAW TO LICENSE YOUR PETS.
Failure to do so is a violation of City ordinances 6.103 and carries
a penalty of a fine up to $150.OD per pet.
PET LICENSES RENEWALS ARE DUE BY 3/15/2016. The City
shall recognize a microchip identification number as the license number.
It shall be unlawful for any dog or cat to wear any ilcense or other city
identification other than that Issued by the City of Blair for such dog or
cat. The City of Blair requires proof of rabies vaccination.
An additional State Fee of $1.25 is being wllected to fund the Nebraska Dog & Cat Operaior Inspection Program
PET # 1 Dog ❑Cat ❑Spayed/Neutered License Fee $
Pet Name �3 �C c�i /°� Ag*e Sex
Color "T�-r1 w4,��d Breed * ,. �• L �d Rep/acement$ **
Declared Dangerous or Potentially Dangerous Dog: ❑ Y ❑ N �u��' ���-E- ���
MICROCHIP # (If applicable) SUBTOTAL: $ ��%'�
RABIES VACCINATION DATE: L`1, r I l-� � (3 yr) (1 yr) ✓ City Tag # *
PET #2 ❑Dog ❑Cat ❑Spayed/Neutered License Fee $
Pet Name Aq�e Sex
Color Breed * Rep/acement $ **
Declared Dangerous or Potentially Dangerous Dog: ❑ Y ❑ N
MICROCHIP # (If applicable) SUBTOTAL: $
RABIES VACCINATION DATE: (3 yr) (1 yr) City Tag #
PET #3 ❑Dog ❑Cat ❑Spayed/Neutered License Fee $
Pet Name Aq�e Sex
Color Breed * Rep/acement $ **
Declared Dangerous or Potentially Dangerous Dog: ❑ Y ❑ N
MICROCHIP # (If applicable) SUBTOTAL: $
RABIES VACCINATION DATE: (3 yr) (1 yr) City Tag #
*PLEASE INCLUDE THE CITY TAG NUMBER IF THIS IS A RENEWAL
** (This fee is due along with License Fee if requesting at the time of license renewal.)
Donation to care for animals: _ $1 _ $3 $5 $10 _Other
***SEE BACK OF FORM FOR BREED SPECIFIC LICENSE REQUIREMENTS
VISA / MC #
Signature
Do Not Send Cash by Mai/ TOTAL ENCLOSED $
Expires: Security Code:
If you have questions, please contact City Ha[I at (402) 426-4191 or by Fax: (402) 426-4195
++++++++++++++++++++++++�t+++++++++++++++++++++++++++++++++++++++++++++++++++++
NEW PET/NEW RESIDENT LICENSING REQUIREMENTS (Marcl7i5/ate fee datenotapplicab/efornewpeis/newresidents)
Newly Awuired Pets: New Residents to Blair:
■ Must be lic�sed within 10 days of ownelstlip ■ Must register pets within 10 days of
■ <OR> at 6 months of age if puppy/Idtten residency.
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06/27/zfl16 MON 11:08 FAX Q0299g8911
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FA,�.M �CIREAU k��tAI�C�IAL SEItVY�ES
JaAnna Van aosklrk, SERVICE ASSOCIATE
5005 5 953RD STREET, OMAHA, Nf= 68137
442•$94-5776
Da�ltt�: June 27, 2016
To: City of Blair - Attn: Brenda From; JDAnna Van Buskirk
Fax: �t02-�26-4195 Phone: 402-218-2669
Pages Int�lwding cover: 2 Fax: 402-�99-89'1 �
small: joanna,yanbaskirk�fbis.�om
Re: i�eith &Kathy Matzen
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OB/27/2p16 MQx 11:08 FAX 402ggq8q11
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P'arrn Btue�.t� IVlember's Choice
Policy #:000796QQ24, KIsIT� IvIATZEN
Term pate 11/�5/2p15 - 1I/2�/2016
PER�pI�AL LIASILITSC A�Tp MEDICAL PAYMETtiTTS
Frerx-►ium for Personal Liability and Medical F'ayrnents
$12$.00
Coverage pescription
Limit
Liability
$SOp,000
Animal Liability
yes
Animal Medical Payments
yes
Medical Payment$ to ethers
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Extra Coverages
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Insured Locations
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pfOtiltSE E`Q (402) 426.-4191 Fax (402) 426-4195
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NOTICE
POTENTIALLY DANGEROUS DOG DECLARATION
NOTICE DATE: February 18, 2016
Effective date of Declaration: February 29, 2016
TO: Kathy Matzen
1415 Park St.
Blair, TIE 68008
Purs�aan� to City of iilair Municipal Code 6-128 the following animals) has been declared a
Potentia��.y Dangerous Dog:
Kingston —Mixed Breed —License #1773
Princess —Mixed Breed —License #1774
This Declaration is based on the attached synopsis of facts.
Based on this Declaration, you are required to comply with the following sections of the City of
Blair Municipal Code and submit the following to City Staff:
1) W�•itten proof from Veterinarian that your dog has been spayed, neutered and
imr,lanted with a microchip, along with the identification number (within 30 days
fr®m declaration).
2) Written proof of public liability insurance of not less than $100,000 (within 30 days
fr��n declaration).
3) Written goof from the Nebraska Humane Society of your attendance and
completion of the required "Potentially Dangerous Dog" class (within 90 days from
declaration).
IMMED_k':4TELY: Sec-6-103 LICENSES. Any person who shall own, keep or harbor a dog or
cat over tie age of 6 months within the City shall, within 10 days after acquisition of said dog or
cat, acquir e a license for each such dog or cat annually by or before January 1 of each year.
C'OMPsE WITII —Both anint�tis were licensed on cce cr4 1, 0.
IMMEDIATELY: Sec. 6-131 DANGEROUS AND POTENTIALLY DANGEROUS DOGS:
RESTRAINED. It shall he unlawful for any person owning, harboring, or having the care of a
dangerous or potentially dangerous dog to permit such dog to go beyond the property of such
person u�Mess the dog is under the control of a person 19 years of age or older, restrained
securely '� y a harness and leash no longer than 6 feet, and properly muzzled to prevent the dog
from biti- .g.
Kathy Matzen
February 18, 2016
Page 2
WITHIN (30) DAYS: Sec. 6-129 DANGEROUS AND POTENTIALLY DANGEROUS
DOGS; SPAYING. OR NEUTERING; MICROCHIP IDENTIFICATION AND LICENSE
REQUIRED. Any dog declared dangerous or potentially dangerous shall be spayed or neutered,
implanted with microchip identification by a licensed veterinarian at the owner's expense and
written goof of spaying or neutering and the microchip identification number being
provided to the City within 30 days after such declaration is entered.
WITHIN (30) DAYS: Sec. 6-132 DANGEROUS AND POTENTIALLY DANGEROUS
DOGS; 'ROOF OF INSURANCE. The owner of any dog declared dangerous or potentially
dangerou: � shall be required to present written proof of public liability insurance of not less
than $1C�'1,000.00 to the City within 30 days after such declaration. Such insurance shall be
required � remain in effect as long as such dog is declared dangerous or potentially dangerous
and shall tie verified annually at the time of licensing.
WITHIN (90) DAYS: Sec. 6-130 DANGEROUS AND POTENTIALLY DANGEROUS
DOGS; :;LASSES REQUIRED. The owner of any dog declared dangerous or potentially
dangerous shall be required to attend, at the owner's expense, a responsible pet ownership class
approved by the City -within 90 days after such declaration is entered. (Please contact the Dawn
Thrapp, Ne1�r�aska Humane Society (402) 444-7800 Ext 220 for information on the "Potentially
Dangerous Dog" classes you are required to attend. These classes are only offered every other
month and attendance at two (2) classes is required for successful completion. Do not delay in
T�egistering to meet your (90) day requirement. Also, you will need to request a verification letter
from the Humane Society as proof of successful completion.)
NOTE: ;, copy of the verification letter must be provided to the City.
You hays. a right to appeal this declaration to the City Council Police Committee. An appeal
of this declaration must be made within ten (10) days of the date of mailing or date of personal
service o` this notice, and must be made in writing to the City of Blair, along with payment of
the appeal fee of two hundred dollars ($200.00), payable to the City of Blair. A hearing will be
held by he City Council Police Committee within ten (10) days of the date of filing your written
appeal; at which time you will have an opportunity to appear and offer evidence to dispute the
declaraticu._,A final determination to affirm or deny the declaration will be issued within ten (10)
days of tl�e hearing by the City Council Police Committee.
The writs �n appeal and the appeal fee should be sent or delivered to the following address: City
of Blair, Attn: Brenda Wheeler, City Clerk, 218 S. 16t" Street, Blair, NE 68008, and clearly
marked �:,� "Notice to Appeal" at the top of the document. Failure to provide sufficient data
regardin��; what matter is being appealed, or failure to pay the appeal fee, will be considered a
waiver of appeal.
Non-con,�liance of any of the above ordinances will result in the owner being declared a
Reckless Owner by the City of Blair, pursuant to Chapter 6, Section 6-138 of the Blair City
Code; anc� will result -in the.revocation of all pet licenses associated with this animals) and
Kathy Matzen
February 18, 2016
Page 3
you will be required to surrender the animals) to any City Law Enforcement Officer or
Animal Control Officer within 24 hours. An appeal of such declaration can be heard by
the City Council Police Committee. The filing fee for such appeal is $200.00.
Enclosed is a copy of Section 6-101 through 6-139 of the City of Blair Municipal Code. The
procedure for determination of Potentially Dangerous Doi may be found in Section 6-128. The
procedure for determination of a Reckless Owner maybe found in Section 6-138.
�-
Phil Green, Assistant City Administrator
CITY OF BLAIR, NEBRASKA
_ -.
v�0 FCC,
( � � a� « �
flair Police ®apartment
�� �,��, � 1730 Lincoln Street
°�"���.s Blair, NE 68008 � �
��;;
i E ,.
�'
]oseph Lager 402-426-4747 (offi )
402-426-7144 (fax)
Chief of Police www.blairpolice.org
To: Rod Storm, City Administrator
From: Joseph Lager, Chief of Police
Date: February 10, 2016
Subject: Potentially Dangerous Dog Designation
Mr. Storm,
On February 8, 2016 our department investigated a report of a dog bite in the 1400 block of Parl< St in Blair
(BPD Incident Report #2016-00085). Through our investigation we learned that the incident was unprovoked.
It is our determination that the animals, "Princess"& "Kingston", owned by the Matzen Family of Blair, NE are
Potentially Dangerous Dogs as defined by Blair Municipal Ordinance 6-125(3)(a)(2).
"Potentially Dangerous dog" shall be defined as one who meets one or more of the
following conditions:
a. Any dog that, when unprovoked:
1. Inflicts an injury on a human that does not require medical treatment, or injures a domestic
animals) either on public or private property; or,
2. Chases or approaches a person upon streets, sidewalks, or any public grounds in a menacing
fashion or apparent attitude of attack; or,
3. Any specific dog with a Known propensity, tendency, or disposition to attack when unprovoked,
to cause injury, or to threaten the safety of humans or domestic animal(s).
The Blair Police Department respectfully requests that these dogs be designated as a Potentially Dangerous
Dogs.
Respectfully Submitted,
(��
Jose M. Lager
Chief of Police
Integrity Service � Vigilance Excellence Respect
CC.
�-�
Incident ID: 20160000085
Page: 3
Associated Names
Incident Data Sheet Report ORI Number: NB0890100
Printed On: 2/10/2016 15:59 (Wed)
Witness
Vict/Susp Rel:
Name: GRINBERGS, MATTHEW J
DOB 5/8/1974 Age/Time: 41
Juv: N
Sex: M
SSN:
Race: White
Home Phone: (402) 426-8147
Work Phone:
Other Phone:
Arrest#
FBI:
SBI: I State
Appr
Appr By:
Charges:
Circumstance:
Visitor: ❑
Military: ❑
Police Dept Associate: ❑
Justif. Homicide:
Follow -Up:
Weap:
Injured: ❑
Reasons for Treatment:
Treated: ❑
Voluntary; ❑
Hospital:
Physician:
Transported By:
Confined: ❑
Refused Admission: ❑
Sent Home: ❑
Condition:
Other Action:
Injuries
Breath Test: ❑
Blood Test: ❑
Refused Test: ❑
Test Results:
Drivers License State: NE Expiration: Number: V00243584
Clothing:
Primary Address: 2104 PARK ST BLAIR, NE 68008
Primary Mailing:
Second Address:
Second Mailing:
Advice of Victims Rights Provided❑ How Notified
Comment:
offense 1 :Animal Control
Employer Occupation Phone Number Employed From Employed To
Incident ID: 20160000085
Page: 4
Associated Names
C
BLAIR POLICE DEPARTMENT
Incident Data Sheet Report ORI Number: NB0890100
Printed On: 2/10/2016 16:03 (Wed)
Victim
Vict/Susp Rel:
Name: PIKE, LAURA K
DOB 7l21/1975 Age/Time: 40
Juv:
Sex: F
SSN:
Race: White
Home Phone: (402) 426-2064
Work Phone: (402) 426-3835
Other Phone:
Arrest#
FBI:
I SBI: I State
Appr
Appr By:
Charges:
Circumstance:
Visitor: ❑
Military: ❑
Police Dept Associate: ❑
Justif. Homicide:
Follow -Up:
Weap:
Injured: ❑
Reasons for Treatment:
Treated: ❑
Voluntary: ❑
Hospital:
Physician:
Transported By:
Confined: ❑
Refused Admission: ❑
Sent Home: ❑
Condition:
Other Action:
Injuries
Breath Test: ❑
Blood Test: ❑
Refused Test: ❑
Test Results:
Drivers License State: NE Expiration: Number: V00244563
Clothing:
Primary Address: 1420 WRIGHT ST BLAIR, NE 68008
Primary Mailing:
Second Address:
Second Mailing:
Advice of Victims Rights Provided ❑ How Notified
Comment:
offense 1 :Animal Control
Employer Occupation Phone Number Employed From Employed To
�- ��--. .
Case#: 2016-00085_ I
Officer: Gunderson/B108
Narrative: Returned call back to Kathy Matzen at 8:23 am at 402-278-2129. She
wanted to know why the dogs were taken. I told her it was a city ordinance I was
following. She said why did I get them licensed and vaccinated? They were just running
loose and should be given back. I told her because they bit a teacher was why they
were taken. I told her I would get the kennel back to her later this morning. After
stopping at the shelter to pick the kennel up I went to the Matzens. At 9:30 am I
dropped of the kennel at the back door and spoke with Miss. Matzen. I gave her a copy
of the rabies ordinance (6-119). She read it and said they could watch them there. I
said that because they have been running loose they were to go to the shelter. She said
we just wanted to cost her more money. I told her to have a nice day and left.
Case Status: Active
Date Typed: 2/10/2016
Typed By: Gunderson/B108
Case#: 2016-00085
Officer: Gunderson/B108
Narrative: Talked with Matt Grinberg on 2/9/2016 at 12:30 pm when he was on his
postal route. I asked him to fill out a statement form and drop it by the station. He said
he would do that. He stopped by later that day and asked to have me give him a call at
work. I called him on 2/10/2016 at the post office here in Blair. They said he was on his
route. I caught up with him at 13th and Nebraska that afternoon. He said he didn't want
to fill a statement out at this time because he didn't want to have to go to court as a
witness.
Case Status: Active
Date Typed: 2/10/2016
Typed By: Gunderson/B108
C
BLAIR POLICE DEPARTMENT
Incident ID: 20160000085 Incident Data Sheet Report ORI Number: NB0890100
Page: 1 Printed On: 2/10/2016 09:41 (Wed)
Incident ID; 20160000085
Offense Code: Animal Control (800)
Occurred Address: 1326 PARK ST
BLAIR, NE 68008
District:
Post:
Source:
Log#:
File#:
Case#:
Situation Found:
Disposition:
Date Reported: 2/8/201612:02
Disp Date:
Date Occurred: 2/8/201612:02
TO 2/8/2016 01:00
Case Status: ACTIVE
Status Date: 2/10/2016 00:00
Shooting: ❑ Domestic Violence: ❑ Hate Crime: ❑ Follow -Up: ❑ Reclassify: ❑
Date Approved By Supervisor:
Supervising Officer:
Division:
Reporting Officer: GUNDERSON, BRETT # 1152
Date Assigned To Investigator:
Investigator Assigned:
Remarks
ON 2/8/2016 AT 12:02 PM DISPATCH RECEIVED A CALL FOR TWO DOGS AT LARGE AT 14TH AND NEBRASKA. I WENT TO THAT ARE
AND BEGAN LOnKING F(�R THE DnGS AFTFR CIRCI ING THE BI nCK FnR A FFW TIME I SAW THE r)r)(;S IN THE Ai 1 FY WAY
BETWEEN PARKAND NEBRASKA OFF 14TH ST. I RECOGNIZED THE DOGS BECAUSE I HAVE DEALT WITH THEM BEFORE. ONE
WAS PRINCESS AND THE OTHER WAS KINGSTON, BOTH BELONG TO THE MATZENS AT 1415 PARK ST. I TRIED TO CATCH BOTH
DOGS BUT THEY WOULD RUN AWAY FROM ME WHEN I WOULD GET CLOSE. THEY STARTED RUNNING AROUND THE HOUSE
NEXT DOOR. THEY CASED AFTER A POSTAL WORKER, (MATT GRINBERG), WHO WAS DELIVERING THE MAIL TO THE HOUSE NEXT
TO 1415 PARK. GRINBERG TOLD ME THE DOGS LIVE AT 1415 PARK BECAUSE THEY HAVE BOTHERED HIM BEFORE. I THEN DOG
BACK IN MY VAN AND FOLLOWED THE DOGS AROUND THE AREA. I WAS ON 14TH AND PARK STREET WHEN BOTH DOGS TOOK
OFF ACROSS THE STREET TO NORTH SCHOOL WHERE A TEACHER WAS WALKING UP TO THE DOOR ON THE WEST SIDE OF THE
SCHOOL. I SAW BOTH DOGS CHASE HER UP THE SIDE WALK AND LUNGE AT HER. SHE LET OUT A SCREAM AND GOT THE DOOR
UNLOCKED AND WENT INTO THE SCHOOL. AT THIS TIME THE DOGS RAN BACK TO THEIR HOME AS MR. MATZEN HAD JUST
PULLED UP. I GOT OUT TO TALK TO HIM AS THE FEMALE PARTY THAT WAS WITH HIM GOT THE DOGS IN THE BACK DOOR. I
TALKED WITH MR. MATZEN AND LET HIM KNOW WHAT HAD HAPPENED. I ALSO TOLD HIM I BELIEVE THAT THE DOGS HAD
CHASED SOME GIRLS AT THE SCHOOL THE WEEK BEFORE AND RIPPED ONE OF THEIR PANT LEGS. HE TOLD ME THAT THE
DOGS RAN OUT PAST HIM WHEN HE LEFT EARLIER AND HE WAS UNABLE TO GET THEM. HE THEN STATED HE WAS GOING TO
GET A KENNEL TO KEEP THE DOGS IN SO THIS WOULDN'T HAPPEN AGAIN. I TOLD HIM I WOULD BE BACK LATER AND LEFT. I
DECIDED TO GO TO NORTH SCHOOL AND SEE IF THE LADY THAT WAS CHASED BY THE DOGS WAS OK. I FOUND OUT THE
TEACHER WHO WAS CHASED WAS LAURA PIKE. SHE INFORMED AT THAT TIME THAT ONE OF THE DOGS HAD BROKE THE SKIN
ON HER LEFT CALF. I TOOK PICTURES OF THE AREA AND GAVE HER A WITNESS STATEMENT FORM TO FILL OUT. SHE ASKED IF I
NEW WHO THE DOGS BELONGED TOO AN I TOLD HER WHO. SHE THEN ASKED IF THEY WERE UP TO DATE ON THEIR SHOTS AND
I TOLD HER I BELIEVED THEY WERE BECAUSE OF A PREVIOUS CASE. 1 TOLD HER I WAS NOT A DOCTOR AND IF SHE WAS
CONCERNED SHE SHOULD GO SEE ONE. SHE HAD TO GO BACK TO CLASS AND I SAID I WOULD PICK THE STATEMENT UP THE
NEXT DAY.
Calls For Service
CFS#: 201600000943 Call Codes:
Disp Recd: 2/8/201613:07 FOLLOW UP
Dispatched: 2/8/201613:07
Arrived:
Cleared: 2/8/2016 13:12
Dispatcher: TY JOHNSON
C
Incident ID: 20160000085 Incident Data Sheet Report ORI Number: NB0890100
Page: 2 Printed On: 2/10/2016 09:41 (Wed)
Officers
Division: Unit Officers)
BRETT GUNDERSON
Supervisor:
Incident ID: 20160000085
Page: 3
Associated Names
��~ -�
�� ;
BLAIR POLICE DEPARTMENT
Incident Data Sheet Report ORI Number: NB0890100
Printed On: 2/10/2016 09:41 (Wed)
Victim
Vict/Susp Rel:
Name: PIKE, LAURA
DOB 7/21/1975 Age/Time: 40
Juv:
Sex: F
SSN:
Race: White
Home Phone:
Work Phone:
Other Phone:
Arrest#
FBI:
(SBI: I
State
Appr
Appr By:
Charges:
Circumstance:
Visitor: ❑
Military: ❑
Police Dept Associate: ❑
Justif. Homicide:
Follow -Up:
Weap:
Injured: ❑
Reasons for Treatment:
Treated: ❑
Voluntary: ❑
Hospital:
Physician:
Transported By:
Confined: ❑
Refused Admission: ❑
Sent Home: ❑
Condition:
Other Action:
Injuries
Breath Test: ❑
Blood Test: ❑
Refused Test: ❑
Test Results:
Drivers License State: NE Expiration: Number: V00244563
Clothing:
Primary Address: 1420 WRIGHT ST BLAIR, NE 68008
Primary Mailing:
Second Address:
Second Mailing:
Advice of Victims Rights Provided❑ How Notified
Comment:
offense 1 :Animal Control
Employer Occupation Phone Number Employed From Employed To
_.
Incident ID: 20160000085
Page: 4
Associated Names
BLAIR POLICE DEPARTMENT
Incident Data Sheet Report ORI Number: N60890100
Printed On: 2/10/2016 09:41 (Wed)
Animal Owner
Vict/Susp Rel:
Name: MATZEN, KATHRYN M
DOB 8/25/1996 Age/Time: 19
Juv: N
Sex: F
SSN:
Race: White
Home Phone: (402) 426-1748
Work Phone:
Other Phone:
Arrest#
FBI: I SBI: (State
Appr
Appr By:
Charges:
Circumstance;
Visitor: ❑
Military: ❑
Police Dept Associate: ❑
Justif. Homicide:
Follow -Up:
Weap:
Injured: ❑
Reasons for Treatment:
Treated: ❑
Voluntary: ❑
Hospital:
Physician:
Transported By:
Confined: ❑
Refused Admission: ❑
Sent Home: ❑
Condition:
Other Action:
Injuries
Breath Test: ❑
Blood Test: ❑
Refused Test: ❑ �
Test Results:
Drivers License State: Expiration: Number:
Clothing:
Primary Address: 1415 PARK ST BLAIR, NE 68008
Primary Mailing:
Second Address:
Second Mailing:
Advice of Victims Rights Provided❑ How Notified
Comment:
Employer Occupation Phone Number Employed From Employed To
Incident ID: 20160000085
Page: 5
Associated Names
BLAIR POLICE DEPARTMENT
Incident Data Sheet Report ORI Number: NB0890100
Printed On: 2/10/2016 09:41 (Wed)
Animal Owner
Vict/Susp Rel:
Name: MATZEN, KEITH M
DOB 7/31/1947 Age/Time: 68
Juv: N
Sex: M
SSN:
Race: White
Home Phone: (402) 426-1748
Work Phone:
Other Phone:
Arrest#
FBI:
I SBI:
State
Appr
Appr By:
Charges:
Circumstance;
Visitor: ❑
Military: ❑
Police Dept Associate: ❑
Justif. Homicide:
Follow -Up:
Weap:
Injured: ❑
Reasons for Treatment:
Treated: ❑
Voluntary: ❑
Hospital:
Physician:
Transported By:
Confined: ❑
Refused Admission: ❑
Sent Home: ❑
Condition:
Other Action:
Injuries
Breath Test: ❑
Blood Test: ❑
Refused Test: ❑
Test Results:
Drivers License State: NE Expiration: Number: G29007553
Clothing:
Primary Address: 1415 PARK ST BLAIR, NE 68008
Primary Mailing:
Second Address:
Second Mailing:
Advice of Victims Rights Provided❑ How Notified
Comment:
Offense 1 :Animal Control
Employer Occupation Phone Number Employed From Employed To
(� (~
�::
BLAIR POLICE DEPARTMENT
Incident ID: 20160000085 Incident Data Sheet Report
Page: 6
Associated Names
Images Description
LEFT CALF.
ORI Number: N60890100
Printed On: 2/10/2016 09:41 (Wed)
Incident ID: 20160000085
Page: 7
Narratives
Narrative Title
2016-00085
Narrative
Case#: 2016-00085
Officer: Gunderson/B108
� • � ' �
Incident Data Sheet Report ORI Number:, NB0890100
Printed On: 2/10/2016 09:41 (Wed)
Locked
Narrative: On 2/9/2016 at 11:08 Officer Leehy and I went to 1451 Park St and took the dogs (Princess
and Kingston) to the shelter for quarantine. We told Mr. Matzen we were doing this because of the
incident yesterday involving the teacher. We informed him he could take them to his vet or the shelter.
He asked if we could wait until his wife got home, but we said no, we are here now. He asked how much
it would cost and I said that would be a question for the shelter to answer. I said it would be easier if I
could take them in the wire kennel he had them in. He said that would be fine. I told him I would bring
the kennel back to him later. While at the resident I noticed there were three dogs and three cats. I also
returned a call to Mrs. Matzen at 11:46 am because she wanted to know why the dogs were taken. I left
a message and told her because they bit a teacher. Later that day I at 12:30 pm I saw the mail man that
was chased and asked him if he would fill out a statement. He said he would and drop it off at the
station.
Case Status: Active
Date Typed: 2/10/2016
Typed By: Gunderson/B108
Created On Created By Updated On Updated By
2/10/2016 09:38 RWILKINS 2/10/2016 09:40 RWILKINS
�- � -
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CITY OF BLAIR C_=; �. ._ POLLS DEPARTMENT
1730 Lincoln St., Blair NE 68008 Phone (402) 426-4747
Statement Fo
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Statement(Name) of .-. CZ C(f �� /(i �, Date of Birth '7 � �Z. /' %�
Address `% � �'i �f �. Phone # %�L'I_ -, ��� ",ZJG�7
1. You have the right to remain silent.
2. Anything you say can be used against you in a court of law.
3. You have the right to tallc to a lawyer and have him/her present wish you while you are being questioned. _
4. Tf you cannot afford to hire a lawyer, one will_be appointed to represent you before questioning, if you wish.
5. Do you understand each of these rights I have explained to you?
6. Having these rights in mind, do you wish to talk to me/us now?_
Officer reading this warning Time
Statement: �� c,��1��t°�
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I have read( d initialed each p ge of the, page statement, It is true and.correct to the
best of my knowledge and given freely a"nd without any threats or promises. .
Signed: � �L� Time: Date: � �-/��
Witness to his statement: � .
Two sided Form
Continuation
I= 1 •
r a Kathy Loudner
no Thursday, April 21, 2011 3:20 PM
T Brenda Wheeler
u ! cta ®og Complaint
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Farmers Insurance 4029345900 p,Q2
Evi�en�e ��In��r�n�e��rMc�r���g�e/(��her
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F A F� M E 1� �
INSURANEE
Thi.sform is not the contract of insurance. It is a memorandum of coverage limited to mortgagee%that interests, provided at their
regriest and applicable to the dwelling or building cat the location laelow. The provisions of the policy will prevail in all respects. This
certificate of insurance cioe.s notaffirmativelyar negativelyamericl, extend, or alter the coverage afforded by the insurance policy_
Should the insurance policy be cancelled bythe company before the expiration date thereof, notice will be given in accordance with the
policy provisions.
Po!lcyNumbet': 3009$•07-60 linden-vrittenBy:
FarmerslnsuranceExchange
Polr'cy Type: Farmers Smart Plan Hometl
6301 Owensmouth Ave.
Policy5tatus: In Force
Woodland Hills, CA91367
Term Effective; 12/4/2019 12:01AM YourFarmers
MickeyCManleyll
Renewal Date: 12/4%2b2b 12:b1 AM Agent:
12111 Anne St
Insured: Keith Matzen and Kathy Matzen
C7maha,NE�r$137-2bd7
1415 Park 5t
(402) 391-1656
glair, NE 684b3-1 E�26
FAX: (402) 934-5900
mmanleyl ra]farmersagent.com
Y+7ur Insured Property
PrapertyAddress
1415 P3rkSt, Blair, NE 58008-1 B2�
�vvera�es
Coverage
zim)t
Coverage
Llmlt
CoverageA-Dwelling
$159,000
CoverageB-Separate Structures
$15,900
Extended ReplacementCost
10°�,($15,9B0)
Coverageb-Loss of Use
$31,i;b0
(In Addition to Covera�ie A Limit)
Coverage F -Medical Payments To Others
$1,000
Coverage C -Personal Property
$87,450
Contents Replacement Coverage
Covered
Building Ordinance or Law
(10°�ofCoverageAorB)
CoverageE-Personal Liability
$300,000
CoverageA
$15,900
IclentityFraudExpenseCoverage
Not Covered
CoverageB
$1,530
Limited Matching Coverage for Sidingr�nd
Not Covered
Roof Materials LossBettlement
Replacement
Roof Materials
Cost Value
fed uctibte
peductlble
Applicable to each covered loss except Windstorm/Hail Loss $500
Windstorm/Hail Loss (3% of Cov. A Limit) $4,770
percent deductibles adjust with changes to Cov. A Limit
farmers,com
ZS 9915 4.13 Page 1 of 2
Farmer's Insurance 402��45900 p,03
Evidence of Insurance for Mortgagee jt7ther Interests (�ontinu�d}
Martr�agees and Other Interests
9stMartgagee LaanMtrmber
Omaha Federal credit Union NatApplicable
3001 5 82nd Ave
Omaha, NE �a124-32Q7
Premium Details
Annual Premium: $2,411.52
>=ee�; �a.00
Tate! Fr�emi[nn; $2,411.52
Balance Due;
WHa Pays: Insured
Mort�a�lee Deductible Clause
EffectiveDate 2ndMartgayee
1/11%2017 NotApplicable
The following provision applies onlyifa mortgagee is named in the Declarations, anti the mortgagee hasforetlosed on the property
prior to the date of loss:
The applicable deductible for any interest ofany mortgagee will be tl5e smallest of the following amounts:
(1) the deductible stated in the Declarations; or
This provision does not apply to loss or damage from earthquake (ifcavered) or hurricane, where a separate, increased deductible
applies to idssor damage caused bythat peril.
������
Authorized Representative
farmers.com
2/2fi/2020
Date
ZS SOTS 9.13 Page 2 of 2
.�' .
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C�ERT.IFICATE.:OF �U"ACC'INATI.ON
Date of Vaccination: 03-05-20
Certificate No. 13514
Next Vaccination on: 03-05-23
Previous: Vaccination:.
VETERINARY CLINIC
OWNER OF ANIMAL
Pet Vaccination Clinic
Kitty Matzen
2911 S. 120th St.
1415 Parks St
Omaha, NE 68144
Blair, NE 68008
402-480-3393
(402) 278-2129
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW
AGAINST RABIES.
Patient information...
PATIENT: Kingston '`� ( „� '� �'
� �'�
TAG NO: 202059
SPECIES: Canine �
BREED: Shih Tzu Mix
SEX: Neutered Male `�"
AGE: 6 years
WEIGHT: 0.00 Ibs
COLOR: White and Tan
MICROCHIP:
MFG BY: ZOETI, S,�RI�L:_347471, EXPI�ES: 07/28/20, /ADMIN; SQ
tt �i�'`�"a I
Signed:
lid Roraback, f�VM License:
Other Val �hations...
®maha Pet Vaccination Clinic
2911 S. 120th St.
Omaha, NE 68144
402-443-2006
OMAHA PET VACCINATION CLINIC - 84th & H -Omaha, NE (402) 443-2006
Printed: 03-05-20 at 10:34a
FOR: Kitty Matzen
1415 Parks St
Blair, NE 68008
(402) 278-2129
Date For
Qty Description
Date: 03-05-20
Folder: 0
Invoice: 17974478
Net Price
03-05-20 Kingston
1 Canine Rabies Vaccination, 3Y
24.00
03-05-20 Princess
1 Canine Rabies Vaccination, 3Y
24.00
03-05-20
Cash payment
-48.00
Old balance Charges
Payments
New balance
0.00 48.00
48.00
0.00
Reminders for: Princess
Last done
03/23 Canine Rabies Vaccination, 3 Y 03-05-20
Reminders for: Kingston
Last done
03/23 Canine Rabies Vaccination, 3 Y 03-05-20
Doctors Instructions
Canine Rabies Vaccination, 3Y
A transient local reaction may occur at the injection site following subcutaneous
administration. In rare instances, administration of vaccines will cause lethargy, fever,
and inflammatory or hypersensitivity types of reactions. If you notice any other these
reactions, consult your veterinarian as soon as possible.
Omaha Pet Vaccination Clinic
84th & H Omaha, NE
(402) 443-2006
www.OmahaPetVaccinationClinic.com
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,;C:E R_T'`I Fri C. A T'E Q F.\/ A C C.J N A T I Q''N =
Date of Vaccination: 03-05-20
Certificate No. 13513
Next Vaccination on: 03-05-23
Previous Vaccination:
VETERINARY CLINIC
OWNER OF ANIMAL
Pet Vaccination Clinic
Kitty Matzen
2911 S. 120th St.
1415 Parks St
Omaha, NE 68144
Blair, NE 68008
402-480-3393
(402) 278-2129
This is to certify...
THAT I HAVE VACCINATED THE ANIMAL DESCRIBED BELOW AGAINST RABIES.
Patient information...
PATIENT: Princess ���� �`
SPECIES: Canine �
TAG NO: 202058
BREED: Shih Tzu Mix
SEX: Spayed Female
AGE: 7 years
WEIGHT: 0.00 Ibs
COLOR: White and Black
MICROCHIP:
MFG BY: ZOETI, SERIAL: 347471, E PIRES �07/2 /20, ADMIN:
� %'
,�9�
SQ
��
Signed: A � ��a � `� -
3094
J ie�Roraback, DVM' License:
Other Vacctinations...
�'�
Omaha Pet Vaccination Clinic
2911 S. 120th St.
Omaha, NE 68144
402-443-2006
OMAHA PET VACCINATION CLINIC - 84th & H -Omaha, NE (402) 443-2006
Printed: 03-05-20 at 10:34a
FOR: Kitty Matzen
1415 Parks St
Blair, NE 68008
(402) 278-2129
Date For
Qty Description
Date: 03-05-20
Folder: 0
Invoice: 17974478
Net Price
03-05-20 Kingston
1 Canine Rabies Vaccination, 3Y
24.00
03-05-20 Princess
1 Canine Rabies Vaccination, 3Y
24.00
03-05-20
Cash payment
-48.00
Old balance Charges
Payments
New balance
0.00 48.00
48.00
0.00
Reminders for: Princess
Last done
03/23 Canine Rabies Vaccination, 3 Y 03-05-20
Reminders for: Kingston
Last done
03/23 Canine Rabies Vaccination, 3 Y 03-05-20
Doctor's Instructions
Canine Rabies Vaccination, 3Y
A transient local reaction may occur at the injection site following subcutaneous
administration. In rare instances, administration of vaccines will cause lethargy, fever,
and inflammatory or hypersensitivity types of reactions. If you notice any other these
reactions, consult your veterinarian as soon as possible.
Omaha Pet Vaccination Clinic
84th & H Omaha, NE
(402) 443-2006
www.OmahaPetVaccinationClinic.com
Farrrrara Insurance 402g345900 p.02
Evidence o� I n��r�nee 'for Mort � ��/Other �►
� � FA�tMEi��
Intere.�t� INSURANCE
This form is notthe contractof insurance. It i.s a memorantiumofcoveragelimited to mortgagee%they interests, provided at their
regr�est and applicable to the dwelling or building rat the location Uelow. The provisions of the policy will Prevail in all respects. This
certificate of insurance does notafFirmativelyor negatively amenei, extend, or alter the coverage afforded by the insurance policy.
Should the insurance policy be cancelled bythe companybefore the expiration date thereof, notice will be given in accordance with the
policy provisions.
Pd1i'cy Number:
3 D098.0 7 -60
F'olicyType:
FarmersSmartPlanHome"'
FalicyStatus:
In Force
Term Effective:
12/4/2019 12:01 AM
f�enewalDate:
12/4/2b2b 12:b1 AM
Jnsrrred:
Keith Matzen and IfathyMatzen
1415 Park St
glair, NE �i8bb3-1 E�26
Your Insured Rroperty
PrapertyAddress
1415 p3rk5t, Blair, NE 68008-1 �24
+�vvera�es
Underwritten Hy: Farmers Insurance Exchange
G301 Owensmouth Ave.
Woodland Hills, CA91367
YourFarmers Mickey C Manley II
Agent: 12111 AnneSt
Omaha, N E �i$137-2bb7
(402)391-1656
FAX: (402) 934-5900
mmanleyl C�farmersagent.com
Coverage
Limit
Coverage
L1mlt
CoverageA-Dwelling
$159,000
CaverageB-Separate Structures
$15,900
Extended FteplacementCost
1 b°�G {$15,9b0)
Coverage d - Loss ofUse
$31,OOb
(In Addition to Cavera�le A Limit)
Coverage F -Medical Payments To Others
$1,000
Coverage C -Personal Property
$87,450
Building Ordinance or Law
Contents aeplacement Coverage
Covered
i 14°� of Cover,�ge A or B)
Covers e E - Personal Liabili
g tY
$300 Q00
�
Coverage A
$15,900
IcientityFraudExpenseCoverage
NotCovereci
CoverageB
$1,590
Limited MatchingCaveregeforSidingr3nd
Not Covered
RoofMeterialsLossSettlement
Replacement
Roof Materials
Cost Value
lied u�f'ible
i7eductrble
Applicat�le to each cave red lass except Windstorm/Hail Loss $v00
Windstorm/Hail Loss (3°I° of Cov. A Limit) $4,770
percent beductibles adjust with changes to Cov. A Limit
farmars,com
�5 8975 4-13 Page 1 of 2
Farmer's Insurance 402g�45900 p•Q�
Evidence of Insurance for Mortgagee/�7ther Interests (continue}
Mortgagees and Other Interests
9stMortgagee toanNumber
C7maha Federal Credit Union NotApplicable
3001 S 82nc1 Avz
Omaha, NE 6$124-3207
Premium Details
Annual Premium' ��,411.52
Fees; �a.00
Tota! Frernium: $2,411.52
Balance Due;
Wtao Pays: Insured
Mortgagee DeductPt�le Clause
Eff€ctiveDate 2ndMartgayee
1/11/Z417 NotAppiicable
The following provision applies onlyifa mortgagee is named in the Declarations, anti the mortgagee hasforetlosed on the property
prior to the date of loss:
The applicable deductiblefor any interest ofany mortgagee will be tl7e smallest ofthe following amounts:
(1) the deductible stated in the Declarations; or
This provision does not epply to Ions or damage from earthquake {ifcovered) or hurricane, where a separate, increased deductible
applies to lossor damage caused bythat peril.
������
Authorized Representative
farmers,com
2/26/2b2b
Date
z5 8475 9-13 Page 2 of 2