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<br />DOUGLAS COUNTY
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<br />THIS COPY CARRIES THE RAISED SEAL OUG NTY,
<br />-AS + , ERTI E
<br />DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE AfITH THE DOUGLAS COUNTY
<br />HEALTH DEPARTMENT, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />11/10/2022 202208146
<br />OMAHA, NEBRASKA
<br />NlyJp,J
<br />LINDSAY HUSE MPH. DNP, RN
<br />HEALTH DIRECTOR
<br />DOUGLAS COUNTY HEALTH DEPARTMENT
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH. AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last, Suffix)
<br />Penelope Rae Stumpenhorst
<br />2. SEX
<br />Female
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />October 23, 2022
<br />d CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand:Isla 3, Nebraska
<br />7. SOCIAL SECURITY NUMBER
<br />507-56-0660
<br />WAGE - Last Birthday,
<br />(Yrs./
<br />75
<br />fjb FACILITY NAME ((:not Institution, give street and number)
<br />Dice House
<br />8c. CITY OR TOWN OF DEATH (Include Zip Code)
<br />Omaha 68124
<br />Ifa. RESIDlNCESTATE
<br />Nebraska
<br />9d, STREET AND>NUMsER
<br />2313 Stardust Lane
<br />9b. COUNTY
<br />Hall
<br />5b. UNDER1 YEAR
<br />Sc. UNDER 1 DAY
<br />SM
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ❑ Inpatient
<br />EI TOutpatient
<br />] DOA
<br />$c cm . OI(TOWN
<br />Grand <Island
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRD) DO I
<br />June 4,1
<br />OTHER 0 Nursing Homet
<br />0 Decedent's Horn
<br />❑ Other (Specify)
<br />7
<br />8d. COUNTY OF DEATH
<br />Douglas
<br />9e. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />10a. MARrrAL STATUS ATTIME OF DEATH 0 Married ❑ Never Marrled
<br />❑ Married butseparatea ® Widowed 0 Divorced ❑ Unknown
<br />11. FATHER'S -NAME :(r4Srst, Middle, Last, Suffix)
<br />Unknown Unknown
<br />13. EVER IN U.S.ARMED FORCES?
<br />(Telt, fisher UMW NO
<br />Give dates of service If Yes.
<br />1Ob. NAME OF:SPOUSE (Rreb Middle, Last, Suffix) If wife, give
<br />Uem Lee Stunipenttotstt!
<br />mime CITfY^UMns''
<br />!YES; Q NO
<br />12. MOTHER'S -NAME (First, Middle, Maiden Surname)
<br />Elaine Luth
<br />14a. INFORMANT -NAME
<br />RYann Kiuthe
<br />141,. REIATIONSINI7O DECNT .
<br />DfiNKIdauiphte ...
<br />16. METHOD OF;DISPQ$LTtON
<br />❑ But1.
<br />"'"0 Donation
<br />® Cremation 0 Entombment
<br />❑:R+►mailal :.D Otho :;SPec(ti<y)
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />19b LICENSE NO.
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Kremer Crematory LLC
<br />17a FIUNERALHDME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />Kremer Funeral Home. Inc.. 6302 Maole Street, Omaha, Nebraska •
<br />CITY / TOWN
<br />Omaha
<br />16c. DATE (Ma,1isy,
<br />November 1,.2022
<br />CAUSE OF`DEATH (See instructions and exarhples)
<br />Chain events- -diseases, injuries, or complicationsahat directly capeod the rtleath, D0 NGT emeri**tfit.Onts such as cardiac arrest,
<br />tt, or ventdgurtr fibrtlUlloh without showing the etiology. DO NOT ABSREVIAGTE. Emar only ons oausez811 a Ikia :Add additional lines If necesaal
<br />IMMEDIATE CAUSE(Final
<br />sease or Condition resulting
<br />-:la deatlll
<br />Segudutlaliy.Set bol piaone, if
<br />8841 leading 10 ttie cause listed
<br />Enter the UNDERLYING CAUSE
<br />(taaeagsam)tir2 iiitmltataa:::,
<br />the everds yesuia akin death)
<br />tAST
<br />IMMEDIATE CAUSE:
<br />a) Lung Cancer
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b)
<br />DUE TO, OR AS A' CONSEQUENCE OF:
<br />c)
<br />0
<br />i!1
<br />DUE TO, OR ASA CONSEQUENCE OF:
<br />d)
<br />18. PART IL OTHER SIGNIFICANT CONOmONB-Conditions contributing to the death but not resulting in the underlying cause given In PART L
<br />Chronic Obstructive Pulmonary Disease, Hypertension, Alcohol Abuse
<br />420. FF'FEMAL£:
<br />Not•pregnsM Ydthin peat year
<br />0 Pregnant at time of death
<br />iiii:❑ Not prggnaM, but waren! within 42 days of death
<br />❑ Nat 140186t.:Ihd pi#gnadt43 days to 1 year before death
<br />© u lketihaa Iftaregnaa W(tIllirais past year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />22d,INJURYATWORKT
<br />❑ YES ❑ NO
<br />21a. MANNER OF DEATH
<br />® Natural ❑ Hmdcide
<br />0 Accident. ❑ Pending Investigation
<br />❑ Suicide ❑ MuidAot be determined
<br />22b. TIME OF INJURY
<br />210. iF-rRANSPORTATION INJURY
<br />OrjvedOperator
<br />0 Passenger
<br />Pedestrian
<br />0 OOxrc(Bpeclfy)
<br />19. WAS aminIdat exam***
<br />OR CORONET CONTACTED?
<br />©YEs'I..►
<br />21c. was AN AUTOPOIT#00 ED
<br />❑ YES NO
<br />21d. WERE AUTOPSY AVAILAMS
<br />TO COMPLETE CAUSE OF DEATHS:
<br />❑ YES D NO
<br />22c. PLACE OF INJURY -At home, farm, street, factory, office building, c t
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22f. LOCATION OF INJURY • STREET 8. NUMBER, APT.NO.
<br />)a DATE OF DEATH (Mo., Day, Yr.)
<br />October 23,2022
<br />23b. DATE Sf(2NED (Mo., Day, Yr.)
<br />October 26. 2022
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />05:23 AM
<br />3d. To the bat of my knowledge, death occurred at the time, date and place.
<br />and due to the causes) stated. (Signature and Title)
<br />Todd M Sauer, MD
<br />25. DID T ..A000USECONTRIBUTE TO THE DEATH?
<br />13I1 YES 0 NO ❑ PROBABLY 0 UNKNOWN
<br />STATE
<br />24a. DATE. SIGNED(Me., Day, Yr.)
<br />IONOUNCED 0
<br />0 (Mo., Day, Yr.)
<br />24d. TIME
<br />24e. On the bash of examination and/or investigation, in my apintan
<br />the time, date and place and due to the sensate) stated. IStgnah
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />OYES ENO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Todd M Sauer, MD, 6307 Center Street Unit 210, Omaha, Nebraska,. 68106
<br />28a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTEW 0
<br />Not Applicable N Is 28a NO ❑V
<br />ES NO
<br />28b. DATE FILED BY REGISTRAR
<br />November 8, 2022
<br />
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