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STATE OF NEBRASKA
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<br />WHEN<THIIS COPY,C:ARRIES THE RAISED SEAL OF SATE OF NEBRASKA,: IT CERTIFIES THE DOCUMENT BELO
<br />'BE A..TRUE•COPY F 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 />1G
<br />E w R ISSUANC..E
<br />3/7/2025
<br />LINCOLN, NEBRASKA
<br />X?.'lr1 j7Itzfi►I'C
<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 />. t:potospstfrs-toms„{tpirirt . Middle, Last, Suffix)
<br />Arnold< F `'Sta'omer`
<br />4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />Hast(t}di3:.:Net raska.
<br />7':$OGIAL SEGUi#i 'Y N McER:
<br />5a. AGE • Last Birthday
<br />(Yrs.)
<br />/71
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />Good:•Samaritan"SO.ciety-Grand Island Village
<br />C, CITY'ORTOWN:t Jt DEATH,(Include Zip Code)
<br />Grand Island 68803'
<br />la. RES►DENCE.STATE
<br /><:Nebraska
<br />9b. COUI(TY
<br />Hall
<br />v. fdi>STREETAND NUMBER : _<
<br />404 West Walnut: Street
<br />10a. MARITAL STATUS AT TIME OF DEATH ® Married 0 Never Married
<br />8
<br />❑ Married, but t pirated 0 Widowed 0 Divorced ❑ Unknown
<br />1::FATHER'S NAME (Prat,' Middle, Last, Suffix)
<br />Herbert .: > Stromer ;:::.
<br />3. EVER IN U.S. ARMED FORCES? Give dates of service If Yes.
<br />(Yes, No, or Unk.) NO
<br />15 ME'I'i30n:0F otafo5MON:
<br />kiirial ;'' j;AOrtatian;;
<br />Crerilatlon ` :Entombment
<br />Removal El Other (Specify)
<br />5bUNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Ba. PLACE OF D.EATH.::.
<br />HOSPITAL E(::Inpatient
<br />-o ER/Outpatient
<br />E3 DOA
<br />9c. CITY OR TOWN
<br />Qon#pha:n.:....
<br />HOURS
<br />MINS.
<br />3. DATECSF4i1
<br />February
<br />tfl� Ra,FIY►,I ':
<br />6. DATE OF BIRTH (INIi',,
<br />MarctL14, 193
<br />OTHER ® Nursing Home/LTC
<br />❑ Decedent's Moms.
<br />❑ Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />BerAPT. NO.
<br />9f. ZIP CODE
<br />68832
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife, give m
<br />.Connie Schidt
<br />12 MOTHER'S -NAME (First,
<br />Isabelle ;' Heitkotter
<br />14a. INFORMANT -NAME
<br />Connie Stromer ,
<br />18a. EMBALMER•SIGNATURE
<br />Not Embalmed
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />BV Cremation Center
<br />74;FUNERAI. HOME ROMIr;RAND MA LING ADDRESS (Street, City or Town, State)
<br />`# lviliuston=Butler Voiland Funeral Home, 1225 N. Elm, Hastings, Nebraska
<br />18b. LICENSE NO.
<br />Middle, Maiden Sums
<br />CITY /'TOWN
<br />Hastings
<br />CAUSE OF DEATH (See lii$t"ructibns and examples)
<br />1s. PART t, 8rltar the chain oredema• dl eases, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory tweet, orventrieular fibrillation without ibmvIng the etiology. DO NOT ABBREVIATE, Enter only one cause on oboe. Add additional lines If necessary.
<br />PA95 InatR;;i
<br />condition re ulilny:
<br />IMMEDIATE CAUSE:
<br />)Respiratory Failure
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />Sequenuapy)istconaltiohs.,if,,b)Neuro endocrine tumor metastatic to: brain ..
<br />ARy ieedi g tothe tiyuse Nstf<d
<br />%Erxer ERLYIND CAUSli:
<br />4
<br />„ Idisaaee or injury that initiated
<br />the events resulting M death)
<br />:DUE TO, OR AS A CONSEQUENCE OF:
<br />c)Severe Malnutrition
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />::d)Chronic Obstructive Pulmonary Dise4 e
<br />acerbaiion:::
<br />le. PART ILGTHE . SIGNIFICANT CONDITIONS -Conditions contributing to the death but.
<br />Transitioned to Hospice Care.
<br />Not'pregnant within pes year R.
<br />PEegnant4t tune of
<br />i..l Not pregnant, but pregnant within 42 days of death
<br />pregnant, but pregnant 43 days tot year before death
<br />ngitetn i If pregnant Within the pant year
<br />2,24. DATE OP; NJURRY (M6..iDa'y, Yr.)
<br />22d. INJURY AT WORKEINP
<br />ra
<br />21a. MANNER OF DEATH' .
<br />Natural Q Homicide:.
<br />Accident Pending investigiHda
<br />0 Suicide ❑ coyid not be determined
<br />22b. TIME OF INJURY
<br />King in the underlying cause given in PART I.
<br />21:b..WTR$ SPORTATION INJURY
<br />'fl Dnver/gperator
<br />pas ginger
<br />El Pedestrian
<br />ElCther (Specify)
<br />hta!t rturar!'s
<br />YES
<br />14b. RELATIONSHIP'
<br />.
<br />18c. DATO0,144. Diy
<br />March 4,,204.>'
<br />tp. WAS M*OICAIs<EXAMINEit
<br />OR CORONER CO TACTMD7
<br />DYES', 1N©
<br />21c. WAS AN AUTOPSYPERFCsitIAED?
<br />0 visa
<br />21d, WERE AUTOPSY
<br />TO COMPLETE CA
<br />0 YES
<br />22c. PLACE OF INJURY -At Home, fevrn, street, factory, office building, co
<br />22s. DESCRIBE HOW INJURY OCCURRED
<br />LOCATION OF:;INJURY=.liTREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 28, 2025
<br />:2:3,b.. DATE::&iQNG_(Mo., Day, Yr.)
<br />11EI�+ 3s° 2025
<br />234.s
<br />cITY/TOWN
<br />23c. TIME OF DEATH
<br />01:20 AM
<br />4the stpf..dby:knitwisdge death occurred at the time, date and place
<br />Ind dtie:to tbecause(s) stated. (Signature and Title)
<br />Michael A. Donner, MD
<br />BUTS TO THE DEATH?
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c«:PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b.
<br />24d. TIME PRONOUN
<br />24:e:On the belle of examination and/or investigation, In my opiniod
<br />: the time, data and place and due to the commis) stated. (Sigttatuft
<br />lw lllD.:TiSAOit'i9 (FT(tl Ft:TISSUE 'DONA'tlf]N BEEN. CONSIDERED?
<br />>' � fun. .'
<br />HAM ,I }. Algid ADDRESS OF CERTIFIER (Type or Print
<br />Michael A. Donner, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />e�(S
<br />FIti:i PROBABLY UNKNOWN
<br />26a. HAS ORGAN 0
<br />YES
<br />26b. WAS CONSENT G
<br />Not Applicable If 28e Is NO
<br />.R
<br />!(. SIGNATU
<br />28b. DATE FILED BY REOISTMAR_I;
<br />March 5, 2025 . _
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