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niiimattaitk. .min 11A ib,,,AlmiligggiNniplOP.... kipriIMMITHtly ttA3 °'. - ckRtttg4VAtsr Se WHEN '' THIS ' COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 12/28/2020 LINCOLN, NEBRASKA 202100590 SARAH BOHNENKAMP ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 2018365 Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death- 1 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Larry L Stutzman 2. SEX Male 3. DATE OF DEATH (Mo.,;Day, Yr.) December 14, 2020 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Howard County, Nebraska (Yrs.) 82 MOS. DAYS HOURS MINS. February 1, 1938 7. SOCIAL SECURITY NUMBER 50742-4952 8a. PLACE OF DEATH HOSPITAL ®'Inpatient OTHER 0 Nursing Home/LTC ❑ Hospice Facility 8b. FACILITY -NAME (if not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) Sc. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Cairo 9d. STREET AND NUMBER 112 Turner Lane Be. APT. NO. 9f. ZIP CODE 68824 9g. INSIDE CITY LIMITS' 111 YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH I ] Married 0 Never Married 0 Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME Of SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Shirley Obermiller 11. FATHER'S -NAME (First, Middle, Last, Suffix) David A Stutzman 12. MOTHER'S -NAME (First, Middle, Malden Surname) I; Emma M Jausi 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) No 14a. INFORMANT -NAME Shirley Stutzman 14b. RELATIONSHIP TO DECEDENT Spouse 15. METHOD OF DISPOSITION ❑ Burial ❑Donafion 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) December 16, 2020 f ] Cremation ❑Entombment ❑ Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAI, HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Aufel Funeral Home, 1123 W. 2nd, Grand Island, Nebraska 17b. Zip Coda 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events -.di , Injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Acute Respiratory Distress Syndrome disease or condition resulting -- onset: ter death 4 Weeks In death> - DUE TO, OR AS A CONSEQUENCE OF: Sequentially list conditions, if b) Viral Pneumonia any, leading to the causelisted tine onset to death on a DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) COVID 19 (disease or injury that initiated onset to death 5 Weeks the events resulting in death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Essential Hypertension, Acute Kidney Injury, Acute Encephalopathy 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES ®NO 20. IF FEMALE: 0 Not pregnant within year 0 Pro nam et time of death0 9 21a. MANNER OF DEATH ® Natural 0 Homicide ❑ Accident ❑Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Dnver/Operator Passenger 21c. WAS AN AUTOPSY PERFORMED? l 0 YES (� NO ❑'Not pregnant, but pregnant within 42 days of death 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year Suicide Could not be determined ❑ ❑ ElPedestrian21d. ElOther (Specify) WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES 0 NO 22a. DATE OF INJURY(Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Speci(y) 22d. INJURY AT WORK? ❑ YES .,,❑ NO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) December 14, 2020 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) December 15, 2020 23c. TIME OF DEATH 04:59 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Manoi Suryanarayanan, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 0 YES 50 NO 0 PROBABLY 0 UNKNOWN 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES E NO 28b. WAS CONSENT GRANTED? Not Applicable If 28a Is NO ❑ YES 0 NO 27. NAME, TITLE' AND ADDRESS OF CERTIFIER (Type or Print Manoj Suryanarayanan, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE gdf-A-' ?1-:44' 7 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) December 22, 2020