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<br />(__ _STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANC€
<br />1218/2022
<br />LINCOLN, NEBRASKA
<br />1.'DECEDENT$;NAM
<br />Dennis Olen
<br />20220868.3
<br />_ n
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA • DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />E (First, Middle, Last, Suffix)
<br />Stoltenberg
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Grand Island, Nebraska
<br />i. SOCIAL SECURITY NUMBER
<br />.8 50740-8936
<br />08b. FACILITY -NAME (I4 not Institution, give street and number)
<br />.41 Health Creighton University Medical Center
<br />8c. CITY OR TOWN OP DI
<br />Omaha 68131
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />TH (Include Zip Code)
<br />ed.;5TIIEET ANC(NUMPEfR'.
<br />3873 North Engiemsn R
<br />9b. COUNTY
<br />Hall
<br />Se. AGE - Last Birthday .
<br />(Yrs.)
<br />67
<br />a.'NIARITAi StATUSATTIMEOF'DEATH El Married 0 Never Married
<br />gr 0 Married, but separated ❑ Widowed 0 Divorced 0 Unknown
<br />1. FATHEITIMAME (First, Middle,
<br />Donald E •Stoltenberg
<br />Last,
<br />Suffix)
<br />1
<br />a. 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk) No
<br />w
<br />16 METHOD OF DISPOSITION
<br />a Qauria Qoonation
<br />CrematiOt l ❑ Entombment
<br />❑Ramovai i ❑ OtheE (Specify)
<br />Sb UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL ® inpatient
<br />❑ ERIOu patient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />22'10407
<br />3. DATE OF DEATH.(Mo.. 5YNI t,
<br />November2 2022
<br />8. DATE OF BIRTH'(Mo., Day. Yr)
<br />March 24, 1955
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Home
<br />❑ Other (Specify)
<br />Bd. COUNTY OF DEATH
<br />Douglas
<br />Be. APT. NO.
<br />9f. ZIP CODE
<br />68803
<br />ce Facility
<br />1Qb( NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maid
<br />Kristie Kaye Payton
<br />iN$Iplr f,'„pr LIMITS
<br />❑'vss Iso
<br />12. MOTHERS NAME (First, Middle, Maiden Surname)
<br />Rosanna Marie Obermeier
<br />14a. INFORMANT -NAME
<br />Kristie Kaye Stoltenberg
<br />16a. EMBALMER -SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />1?a. FUNERAL HOME NAME AND MA UNG ADDRESS (Street, City or Town, State)
<br />A,ll Faiths uneral Home, 2929 S. Loeust'Street, Grand Island, Nebraska ;;:
<br />CAUSE OF DEAT
<br />16b. LICENSE NO.
<br />CITY / TOWN
<br />Gibbon
<br />(See InStrucii+artsand examples)
<br />IS. PART I, Enter the chain of injuries, or complicetlona-that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Add additional lines If necessary.
<br />14b. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />16c. DATE (Slra .DayXr )
<br />November 25 <2022
<br />fTATE':>:.:..
<br />Nebraska
<br />.1 Zrpf ode
<br />::88801
<br />IMMEDIATE CAUSE P11th)
<br />dlsesSe or condition readlan;j:
<br />in death#
<br />Sequentially list conditions, If
<br />any, batting to the:caupNated
<br />the events resulting In death)
<br />LAST
<br />IMMEDIATE CAUSE:
<br />a) Septic Shock
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) Serratia Pneumonia
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />C)
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />Days
<br />18. PART OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I
<br />Type A.AortieDISseCtii' n, Heart Failure, Respiratory Failure, Acute Kidney Injury
<br />r O IFFEMALE:
<br />❑ NOtpregnsntwlthinpeatyear
<br />.;. pregnant at bine or death
<br />❑ ivad.pragnent, but pragnant within 42 days f death
<br />S. 0 Not pregnant, but pregnant 43 days to 1: -year before death
<br />.:..,❑.,UdknownK:pmgnatawlthinthepastyear
<br />22d. INJURY AT WORK?
<br />c3 YES QNO..
<br />LO
<br />2a.DATE
<br />22f.
<br />tfiiJURY (Mo. Day, Yr.)
<br />21a. MANNER OF DEATH
<br />Natural ❑ HomisIde
<br />❑ Accident ❑ Pending Investigation
<br />❑ suicide ❑ Cottle not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />CATION OF INJURY STREET 8: NUMBER, APT.NO.
<br />29a. DATE OF DEATH (Mo., Day, Yr.)
<br />November 22 2022
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />December 5, 2022
<br />23d Tote. beat of my knowledge, deft( occurred at the time, date and place
<br />sad due to the aeua(s) stated: (Signature end Title)
<br />Erin M. Etoll, MD
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />09:14 PM
<br />25. DID TOBACCO U$E CONTRIBUTE TO THE DEATH?
<br />YES ® NO 0 PROBABLY 0 UNKNOWN
<br />2
<br />FINJURY•A1
<br />z
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<br />21b, IF TRANSPORTATION INJURY
<br />CDrninnoperator
<br />Passenger
<br />❑ Pe"destrian
<br />0 Other (Specify)
<br />•
<br />19. WAS MEr1iCAL::(AMINER:;:
<br />OR ii GONTACTsci t
<br />❑ ye$ NO'
<br />21c. WAS AN AU
<br />0 YES
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑ YEs ❑ NO . .
<br />e, farm, street, factory, office building, construction
<br />STATE 411104
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH .'
<br />24c PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEA©
<br />240 On the basis of examination and/or investigation, In my opinion tteatSt cdeurted: at
<br />the time, dateand place end due to the cause(s) stated. (Sign tune end TB's)
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES CEJ NO
<br />. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Erin M. Etoll, MD, 984455 Nebraska Medical Center, Omaha, Nebraska, 68498
<br />28a. REGISTRARS SIGNATURE
<br />26b. WAS CONSENT GRANTED? :.
<br />Not Applicable If 28a is NO 0 YES
<br />28b. DATE FILED BY REGISTRAR (Mo., Day,Yr.)
<br />December 6, 2022
<br />
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