Laserfiche WebLink
:197 <br />c <br />O <br />0 <br />U <br />C <br />7 <br />0 <br />V <br />0 <br />E <br />0 <br />X <br />m <br />Q <br />V <br />m <br />E <br />IC <br />IRI <br />'a <br />T <br />a <br />i <br />O <br />LL <br />20180'7082 <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES MANCE AND SUPPORT <br />VITAL STATISTICS <br />CERTIFICATE OF DEATH 299988 <br />This certifie,"thit*ocument to be a true copy of an original record on file with Vital <br />Statis;<ic5, Douglas Coun.y Health Department, Omaha, Nebraska. Certified copies must have <br />a rai_.euin-the,area to the left. Reproductions of this green certificate are not <br />legal copies, <br />Date issued: <br />JUL 10 2001 <br />Registrar: <br />90et4X414 <br />I. DECEDENT - NAME MAST INDOLE LAST <br />Bruce Thomssen Stoltenberg <br />2. SEX <br />Wale <br />1 DATE OF DEATH ,/Aawrat Day Yew <br />July 3. 2001 <br />A CITY AND STATE OF BIRTH ;e not n USA. name cosotyl <br />Se AGE • Lar Birthday <br />UNDER 1 YEAR <br />UNDER 1 DAY <br />B DATE OF BIRTH Akre! Day Yew <br />Grand Island, Nebraska <br />(Yra.l <br />` 77 <br />50 M05. DAYS <br />SC. HOURS MINS <br />February 24. 2001 <br />Z <br />1)2 <br />0 <br />7 SOCIAL SECURTIY NUMBER <br />506-26-8088 <br />Ba. PLACE OF DEATH <br />HOSPITAL. <br />-- <br />►`�e�J <br />f <br />inpaaar8 OTHER Nursing Home <br />ER OleOeaent ❑ Residence <br />V <br />w <br />0 <br />60 FACILITY 01010 4not �nMMAn1. gni seen and ousted <br />Nebraska Health System -Clarkson <br />❑ DOA ❑ Other SoeceuI <br />Se CITY TOWN DA LOCATION OF DEATH <br />Omaha <br />87 INSIDE <br />Yes <br />an, LIMITS <br />r No ❑ <br />8e COUNTY OF DEATH <br />, . . <br />9a. RESIDENCE - STATE <br />Nebraska <br />90 COUNTY <br />Hall <br />9c CITY. TOWN OR LOCATION <br />Grand Is and <br />90. BEET AND NUMBER /irc/udeg Zvi Code) <br />4418S. Hngl®ai lid' 68803 <br />9e INSIDE <br />Vero <br />077 <br />LIMITS <br />No ❑ <br />10. RACE • leg., Wide. Black. American Indian. <br />etlrS01041 White <br />11. ANCESTRY leg.. Baird Mexican. German. elcl <br />15os"' AmericanNEVER <br />12 nil <br />7 <br />l I <br />MARRIED a WIDOWED <br />noiv,..D <br />MARPoED I 1 <br />13 NAME OF SPOUSE r8 verb. goy m6raen name) <br />Mary Trentman <br />144 USUAL OCCUPATION /Gam k,o1 ol ocra Gone dump mor <br />140. KIND OF BUSINESS INDUSTRY <br />13. EDUCATION NOW <br />cn <br />Z <br />z <br />d eorarg ale. ever dner.0) <br />Farmer <br />Agriculture <br />(Specify arta grade cornpleled1 <br />Elementary or Secondary 10-121 college :1-4 a 5.1 <br />12 <br />UJ <br />CC <br />c <br />16. FATHER - NAME HIST MIDDLE LAST <br />_. <br />Rudol•h • . - I. - • <br />17 1.40T14ER FIRST MIDDLE MAIDEN SURNAME <br />.e - • I.II---m <br />a <br />III <br />ta WAS DECEASED <br />(Yea. ,0 Or UV.) <br />NO <br />EVER IN U.S. ARMED FORCES! <br />ill yes goo war and Caws al avveesl <br />1ya INF.••• T - NAME <br />WaryStoltenberg <br />190 INFORMANT MAILING ADDRESS 'STREET OR R.F 0 NO. CRY OR TOWN. STATE. ZIP) <br />4418 S. Engleman Rd.. Grand Island Nebraska RRn1--- <br />20�fABA MER - SIGNA RE & L C •/-.q/ 21a. <br />"/�?7, j„ /ate^c/� <br />METHOD OF DISPOSITION <br />74B.41 ❑Ren..,,, <br />210 DATE <br />July 7, 2001 <br />21c. CEMETERY OR CREMATORY NAME - - - --- <br />St. Libory Cemetery <br />FUNERAL HOME - NAME <br />All Faiths Funeral Home <br />❑Cr.n,a4n Donaean <br />214. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />St. Libory, Nebraska <br />2217 FUNERAL HOME ADDRESS (STREET OR RFD. NO. CITY OR TOWN. STATE Zit <br />2929 S. Locust St. Grand Island, Nebraska 68801 <br />21 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER UNE FOR Ial. IN AND Ice Interval between onset ono xam <br />P" al tA124Nro 1'1444 1%0(441Ai c. i" <br />D <br />U <br />DUE TO�d1�A5 A CONSEQUENCE OF <br />Irv w vel barmen onset ane main <br />(a 4 EV ku.,0N11 it - <br />DUE TO. OR AS A CONSEOUENCE OF i kerva' 5061000110(100150000(11 <br />1 <br />ICI <br />OTHER SIGNIFlCANT CON01710NS - PCondemns51. trtuang to ale death Nu /n41108.1.0 PART el IF FEMALE WAS ITTH-ERE A I�-1I 1 24 AUTOPSY <br />PATTT' y Ate•, _ 0. A-tic�i tic II _ pfie - e(�-�.J 1` T, <br />PREGNIANCY M THE�PAST Yes No <br />WAS CASE REFERRED TO MEDICAL <br />IXAMINER OR COROrNEER' <br />Yes 7 o PI <br />26a <br />• Accident II Undetermined <br />260 DATE OF INJURY (Aso_ Day. Yr.) <br />26c. HOUR OF INJURY <br />M <br />26d DESCRIBE HOW INJURY OCCURRED <br />• Sracde • Pending <br />. Homicide investigation <br />28e. INJURY AT WORK <br />yea a No ❑ <br />261. GlPLACE OF INJURY -/A1 homy. land steel. lackey <br />ace MriOing et <br />26g. LOCATION STREET OR RF D. NO CITY OR TOWN STATE <br />27a. DATE OF DEATH /AAT. Day Yr) <br />July 3, 2001 <br />28a. DATE SIGNED ;Mo. Day. Yr) 280 TIME OF DEATH <br />A 14 <br />a <br />270 DATE SIGNED ,Ab. Day Yr) <br />/0I July c% <br />` 27c TIME OF DEATH1- <br />3:35 pM <br />C <br />>sy <br />28c PRONOUNCED DEAD Ab.. Day. Yrl <br />284. PRONOUNCED DEAD /Mwr; <br />M <br />270 io t60 Oast al my knp Deet occurred r theoma. nate andpace and . d ele <br />cauaelsl staved. wMgdllo!%ye�► �AA� /n <br />ISgnalura and TOteI ► ` / a ._. 'd' ' / <br />.5 <br />'. <br />10. <br />28e. On me Owe d examination and n I mesegation, In my opinion pealn occurred al • <br />dile time. dew and plica ar�gUe to dile camels steal <br />SgnaNre and Taal ► <br />29 pD TOBACCO USE CONTRIBU E TO:THE DEATH! <br />YES <br />YESNO L+NKNOWN <br />30.a HAS - AN OR TISSUE DONATION BEE CONSIDERED, <br />YES 1 NO <br />430.0 WAS CONSENT GRANTED' T 77 - <br />YES NO <br />31 NAME AND . OTN'iE SS OF CERTIFIER IPHYSK:JAN.•CORONER S PHYSICIAN OR COUNTY ATTORNEY, Type or Prm <br />D T1 . S `\`i rd 14(34-0. FG,- rill, S;e IS Crti-rd. I).e (42131 <br />32a. REG-ST74AP Alt7 • I <br />'/�/J// <br />320 DATE FILED BY REGISTRAR Ab Day Yr <br />Jill 1 0 2rint <br />This certifie,"thit*ocument to be a true copy of an original record on file with Vital <br />Statis;<ic5, Douglas Coun.y Health Department, Omaha, Nebraska. Certified copies must have <br />a rai_.euin-the,area to the left. Reproductions of this green certificate are not <br />legal copies, <br />Date issued: <br />JUL 10 2001 <br />Registrar: <br />90et4X414 <br />