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<br />STATE OF NEBRASKA
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<br />HEN THIS oft CARR/ES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW,
<br />...;',4 TI UE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND :•
<br />-HUMAN' SER VICES, VITAL. RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS .
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<br />004
<br />DATE OF ISSUANCE
<br />.LINCOLN, NEBRASKA
<br />2023003
<br />4
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEATH:
<br />AND HUMAN SERVICES .:
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1DEI.epENrS IAME (first i' Middle,. Last, Suffix)
<br />Denny$ on Steaitenberg'.
<br />4 CITY
<br />AND S"1'ATE pl,:m RITORY;:OR FOREIGN COUNTRY OF BIRTH
<br />rand island Neb'ra$ka'
<br />CIAL SeCuRl1
<br />74041936
<br />UMBER
<br />Sa.:kiGE - Laet Birthday'
<br />(Yrs.)
<br />` Sb: F CILUTY.NAME (if not Institution, gide street and number)
<br />GHIHealth s✓rt3lglitort Universiity Medical Center
<br />bb UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />22 16697
<br />3. DATE OP DEi4TN #Mc:; Itay Ytr');:
<br />• November 22 2022
<br />6 DAtE OF BIRTH#Mo„• D(sYr
<br />March 244
<br />OTHER 0 Nursing Haniq/LTC
<br />❑ Decedent's Home. •
<br />❑ Other, (Specify)
<br />MOS.
<br />DAYS
<br />8a `PLACE OF, DEATH
<br />HOSPITAL jf :IInpatient
<br />0 ER/Ou patient
<br />❑ DOA
<br />HOURS
<br />MINS.
<br />8c, CIIY OR TCMMN OF DSATW (Include Zip Code)
<br />aIle 68139
<br />91: eteibeNCE STATE
<br />Nebraska .11
<br />9d STREETANDNUMEEt#
<br />3873 Nt>rti Eripieman Road
<br />9b. COUNTY
<br />Hall
<br />1(1a.•MARITAL STATU$iAVn(ME OF, DEATH ® Married 0 Never Married
<br />• 0 Married? butseparated Ij Widowed 0 Divorced 0 Unknown
<br />i' ie4THER SNAMI?' #I?irSt
<br />Donald e Stolte:nt
<br />13 EVER IN U.5- ARM
<br />es,'No;'or. tinl4:) No
<br />as
<br />Middle Last Suffix)
<br />CES?
<br />5. METHOD QF DI$P smON
<br />Q;Buriai ❑Donation
<br />Cremator] Eritontimlent=
<br />.Rnlovai j❑Other{Specify
<br />1te :FUNERAL
<br />ani l=a;lttis
<br />ve dates of service if Yes.
<br />I8d. COUNTY OF DEATH
<br />Douglas
<br />9c. CITY OR TOWN
<br />Grand island
<br />Oe. APT. NO.
<br />9f. ZIP CODE.
<br />68803
<br />1t)t. NAME OF SPOUSE (First; Middle, Last, Suffix) If wife; give dan.na
<br />Kristie Kaye Payton
<br />12. MoOTHERS4 AME (First, Middle,
<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 />OME.NAME'AND•MAILiNG ADDRESS (Street, City or Town,.State)
<br />tlneral Home 2929 S. Locust Street, Grand Island :Nebraska
<br />16b. LICENSE NO.
<br />CITY ! TOWN
<br />Gibbon
<br />CAUSE OF DEATH (See instructions and examples)
<br />8: PART t: Enterthe chain of events= diseases; Injuries, orcomplications.thet directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />'.'_respiratory arreet tit: Ventrlcplarflbnpation without Showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />...IMMEDIATE CAUSE:
<br />18(Fiit ..
<br />or'Ctitldirtd;�:rss�!
<br />tit):
<br />uenttagy gst condition
<br />eMl, leadiogtytthe.:aanestbetad. •
<br />Ehret the UN15ERLYiNC EAUSE ;
<br />(dtseasiitpr jnturydrat'irdelated. .
<br />aie:events resulting in death)'.:
<br />a) Septic Shock
<br />INTERVAL
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />b) SerratiaPneumonia
<br />DUE TO, OR AS A: CONSEQUENCE OF:
<br />DUE' TO, 0
<br />AS A. CONSEQUENCE OF:
<br />tato
<br />Days ' •
<br />tQj
<br />aARTil OTH
<br />Type A Aorto
<br />ER SIGNWICANT.CONDITIONS.Conditions contributing to the death but not.
<br />L0sE
<br />1sCttttin Heart Failure; Respiratory Failure, Acute Kidney Injury
<br />ultitlg'iY) the underlying cause given in PART is
<br />•IF FEMAL•
<br />E .:.
<br />© Not preg7ta f wiattr past year
<br />Program et arra or death :<.:
<br />Nat -orient,but)sregnant wtihhi.42 day's of death
<br />Not pregnant, butpregnent 48 gays to year befdre
<br />Unkn *n7i (.regnant within the past year,.•
<br />URYi
<br />229: INJURY AT WORK?
<br />,❑ YES: ONO
<br />I iCAT(OP °P INJ
<br />ath
<br />21a. MANNER OP DEATH
<br />Natural ❑ Homintde
<br />❑ Accident ❑Pending tnvastigation
<br />❑ Suicide ❑Could not be determined
<br />22b. TIME OF INJURY
<br />21b. IF TRANSPORTATION INJURY
<br />DnVYrlOperator
<br />1.3 Passenger.
<br />Cf:Pedestrian
<br />0 Other(Specify)
<br />1:9, WAS MED ....... .
<br />OR.CORONER.iNTAC.'
<br />❑ YES:: 5 NO : :
<br />21c. WAS AN AUTORSY PEJR?ORML09
<br />❑ YES 4110
<br />21d. WERE AUTOPSY!
<br />TO COMPLETE
<br />O YES
<br />AY{At4
<br />DEATH?
<br />22c. PLACE OF INJURY At home, farm, street, factory, office building, construction a
<br />220::DESCRIBE HOW INJURY OCCURRED
<br />URY'i :STREETd,,NUMBER. APT.NO.
<br />23a. DATE OF: DEATH (MO., Day, Yr.)
<br />Novverriber'22, 2022'
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />E OF DEATH
<br />23b..DATE$IGNED (Mg...,:.Day;, Yr.) 23c. TIME OF DEATH
<br />[mber:5 2022:,, 09:14 PM
<br />3d 1 fhb best pf niy tmowiedge, death occurred at the time, date and place
<br />true ie the>caoSe(s) stated: (Signature and Title)
<br />toll , MD
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24d. TIME PRONOtmcED,DEAD::..,.
<br />. On the boots of examination and/or investigation, in m ei:Mi110 i
<br />the hme;'tlate and place and due to the causes) statetk;(Signi
<br />25: Dip TOBACCO USE,C,ONTRiSUTE TO THE•DEATH?
<br />YES �NO]PROBABLY: 0 UNKNOWN
<br />27, NAINE, T)`n«lS ANb A06ixESS OF CERTIFIER (Type or Print
<br />Erin Ali Etii! MD, 384455 Nebraska Medical Center, Omaha Nebraska, 68188
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />DYES
<br />NO
<br />26b. WAS CONSENT'ORAN1
<br />Not Applicable if 26a is NO.
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (MO.,;D
<br />December 6; 2022
<br />
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