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<br />STATE OF NEBRASKA '� � � � � � � �j �-,,�, ,
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF H�ALTH AND. U�MAN SEaVIC�S, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NL pF hlEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V�'PAL .`t �
<br />, �� , �'�' , d � '
<br />DATE OF ISSUANCE P
<br />j����a��"�l !' ,
<br />06/04/2012 s`�A��'�'s, cqo�R . '• y�:� �f,
<br />AS�S�A T�,TE,R�6ISTRAI`t�' ;�
<br />DEI�GKTM +BI� b`M�,4 ��Z�'l ALVQ _ •�
<br />LINCOLN, NEBRASKA HUh9�IN Sl��ES : r; `,,
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERIII,CE',�y �'•, ,/"� l t`.'� `' �'
<br />. �.!�,�._� . cti- _ � �'12 01922
<br />CERTIFICATE OF DEATIi r"�� "' � • •` � � �". `' . • �� ` °"'"
<br />1. DECEDENT9-NAd1E (First, Mlddle, Last, Suffbc) 2. SDC '�� ., �� � OF DkATIi'(Mo„ Day, Yr.)
<br />Dale William Stolle Male "' �'� y � e a�y 2�, �012
<br />4. CITY AND 9TATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 8a. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 1 DAY ; 8: DATE �F BIRTH (Mo., Day, Yr.)
<br />(Y�•1 MOS. DAYS HOURS flI�NS.
<br />Grand Island, Nebraska 62 March 15, 1950
<br />7. &OCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br />548-7&2218 OS pITAI. � �np8U8M OTHER ❑ Nursing Home/LTC � Hospice Faeliity
<br />8b. FACILITY•NAME (it rrot InsUtutton, plve street and numher) � ERIOutpaUent ❑ Decedent'e Home
<br />�
<br />� Saint Francis Medical Center ❑ oon ❑ aner �spec�ry�
<br />� 8c. CITY OR TOWN OF DEATH prtclude Zip Code) 8d. COUNTY OF DEATH
<br />o Grand Island 68803 Hall
<br />� 8a. RESIDENCESTATE 8b. COUNTY 9c. CITY OR TOWN
<br />w Nebraska Hall Grand Island
<br />� 8d. STREET AND NUMBER . APT. NO. 9L ZIP CODE 9g. INSIDE CITY LIMffS
<br />" 1830 North Ta lor 68803 � r�s ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Marrled ❑ Never Mlarried 10b. NAME OF SPOUSE (Flrst, Middle, Laet, Suffbc) Hwffe, gfve �Iden reme
<br />€ O�mea, bue senaracea ❑ nnaowea ❑ oh.oreea ❑ unk�owo Nancy Lea Koester
<br />� 17. FATHER'S-NAME (Firat, Middle, Lasf, Suftix) 12 MOTHER'3-NAME (Flret, Middle. Malden Sumame)
<br />Wllmer J Stolle . Nancy H Fuerstenau
<br />E 13. EVER IN US. ARMED FORCES? Give dates of service H Yea. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br />s �res, No, or umc.► No Nan Lea Stolle Spouse
<br />,� 15. METHOD OF DISPOSITION 16a. EMBALMERSI(iNATURE 18b. LICENSE NO. 16e. DATE (Mo., Day, Yr.)
<br />� t] suriai ❑ oo�uon Not Embalmed May 31, 2012
<br />� CremaBon ❑ ErRombrtrerrt 16d. CEMETERY, CREMATORY OR OTHER LOCATION CI'fY I TOWN STATE
<br />❑ Remo,�ai ❑ Other (Speci(y) Central Nebraska Crematlon Services Gibbon Nebraska
<br />17a. FUNERAL HOM1I� NAME AND MAILING ADDRESS (Street, Cily or Town, State) 17b. Zlp Code
<br />All Falths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE OF DEATH See instructions and exam les
<br />18. PART I. Fster the eha�n M eveMe-�seaeea, InJurlee, or compUcatlo�rthat dlrectiy mused the deaM. 00 NOT errter terminal eveMe euch ae cardlac arreet, = APpROXIMATE INTERVAL
<br />respiratory arreat, or veMrlcutar flbrillatlon wRhout shorinp the edWogp. DO NOT ABBREVIATE EMer only o�re mu� on a Ilire. Add edditlonal Il�rea Ii �receseary. �
<br />IMMEDIATE CAUSE: ; onset to death
<br />IMMEDIATE CAU9E (Flnal a) Septic�mia � 12 Hours
<br />di6ease or condttlon resulUng '
<br />�� �') DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />s�„e,m�, u� �o�,nuo„a, n b) MetastaUc Squamous Cell Carcinoma Of Lung � 3 Months
<br />arry. teading to the eauae Ils�d
<br />on Nre a DUE TO, OR AS A CONSEQUENCE OF: ; onset to death
<br />Emer Ne uNU�unNO cause �)
<br />(dteesse orinJurythatinitlated
<br />the e"e"t° res�'ni"e �"'�U DUE TO, OR AS A CONSEQUENCE OF: : o�et to death
<br />� d) � �
<br />18. PART U. OTHER SIGNIFlCANT CON�ITIONS-CorMitlo� eonMbutl� to the death but rrot resulUng in the umleriying cause gtven In PART 1. 78. WAS MEDICAL EXANUNER
<br />Respiratory Failure OR CORONER CONTACTED7
<br />� ❑ YES � NO
<br />u, 0. IF FEMALE: 27a. MANNER OF DEATH 21b. IF TRANSPORT/iT10N INJU 21c. WAS AN AUTOPSY PERFORMED7
<br />� � Nct P�eB�eM wkhln �at Y� � NaNrsl � HoMcide � Driver/CPerstar �� � NO
<br />� � PreB�t at tlme of tleath � AaddeM � Pemm�g Invead8�on ❑ Pe��Be�'
<br />a� � NM pregna�rt, but prepnant wfthln 42 days of deatl� gwdde CoWd nM be tletermhred � P���" 21d. YVERE AUTOPSY FlNDINGS AVAILABLE
<br />� NM P�eB�eM. but P�eB�eM 49 uari to 1 Yea► betore death � � � Other (8P��h) TO COMPLETE CAUSE OF DEATH7
<br />� ❑ Unlmown H prepnant wtthln the paet year ❑ YES ❑ NO
<br />°' 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22e. PLACE OF INJURY At home, farm, etreet, taetory, o18ee bullding, conatruedon aRe, eta (Sp�ify)
<br />E
<br />$
<br />� 22d. INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
<br />1�-
<br />❑ ves ❑ No
<br />22L LOCATION OF INJURY • STREET 8 NUMBER, APT.NO. CITYlTOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) � 24a. DATE SIGNED (Mo„ Day, Yr.) 24b. TIME OF DEATH
<br />s May 29, 2012 � �
<br />��� 23b. DATE SI(iNED (Mo„ Day, Yr.) 23c. TIME OF DEATH ��� r 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />E Z Ma 31, 2012 03:31 PM � a�
<br />$� � To tlre beet oT my ImowledBe. tleaM xcurted at the time, da[e anA P�eae $��� 24e. On the basta M e�mmlmtlon anNOr inveaflgatlon. ln my oPlNOn death occurtad at
<br />�- wM due to the causefe) sleted. (St9�+re and TItle) � $ dre tlme. date e� Piace arM due lo the cause(s) afated. (Slpnature and T(Ue)
<br />~� David R. Colan, MD ~ g�
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH7 28a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 28b. WAS CONSENT GRANTED?
<br />� YES ❑ NO ❑ PROBABLY ❑ UNIaIOWN ❑ YES � NO Not Applicable H 28a la NO ❑ YES ❑ NO
<br />2. L D TI IER Y 1 R I ype or Prirh)
<br />David R. Colan, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGISTRAR'S SIGNATURE 28b. DATE FlLED BY REOISTRAR (Mo„ Day, Yr.)
<br />May 31, 2012
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