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<br />*IS Copy CARP1'ES THE RAISED SEAL OF STATE OF' N,1' BRASKA;IT CERi%FIES THE DOCUMENT BELOW TO
<br />BE A TRUECOPY`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 />£LATE OP ISSUANCE
<br />• 27250026.
<br />LINCOLN, NEBRASKA
<br />202602256
<br />- jadidi &tiun
<br />SARAH BOHNENKAMP T
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT QF HEALTH AND HUMAN SERVICES
<br />t. DECEDENT'Sr 4ME (Fill Middle, Last, Suffix)
<br />Cariple R €Stt : n
<br />CERTIFICATE F DEATH
<br />4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />St : Pay!, Nebraska
<br />?:`SOCIAL SECURITY NUMBER
<br />507-90.3209
<br />6a. AGE - Last Birthday
<br />(Yrs.)
<br />. 64
<br />1
<br />nter8tsIjNDEItL1!IyBCAWS' C)
<br />(,haws or injury that Inhaled
<br />its FACILITY -NAME (N not Institution, give street and number)
<br />:":CHt: ealthSt. Fiancis
<br />>Ie. CITT OR;TOWN OF DEATH (Include Zip Code)
<br />Granditallin& 68803
<br />9a. RESIDENCE -STATE
<br />go. 8n.EETANDNJM R 1
<br />3233 W 17#lx St
<br />9b. COUNTY
<br />Hall
<br />10a. MARITAL STATUS AT TIME OF DEATH Married 0 Never Married
<br />0 Mwrled.but separated ❑Widowed 0 Divorced 0 Unknown
<br />ff FAl'IlER"S-NAME first,' ; 16Iddle, Last, Suffix)
<br />Owen Clelhlbta
<br />13. EVER IN U.S.ARMEDPORCES7
<br />(Yes, No, or Unk.) No
<br />:a.':METHOD:OF DIBPearrobN
<br />uricl ci Donatto :. /
<br />Cl-corrailext.p Entombment
<br />❑ Removal ❑ Other (Specify)
<br />l6b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />5c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL 23Inpatient
<br />❑ ER/Otp uadent
<br />DOA
<br />A 0 Other (MINI
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH -BOO, Oh,
<br />February 8, 2028 .:.........:
<br />6. DATE OF BIRTIN (Mo., Day, Yr.)
<br />May 18,1961._
<br />9c. CITY OR TOWN
<br />Grand Wand
<br />OTHER 0 Nursing IldittslLTC
<br />0 Dscsdent's Horne
<br />ed. COUNTY OF DEATH
<br />Hall
<br />lj
<br />Bs. APT. NO. 9f. ZIP CODE
<br />68803
<br />❑ Ma.plar FattIMY
<br />ag. INSMI8 CITY LIMITS.
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden nape
<br />Daniel Stutzman
<br />14a. INFORMANT -NAME
<br />Daniel Stutzman
<br />16a. FUNERAL DIRECTOR SIGNATURE
<br />Stacie L Cook
<br />12. MOTHER'S -NAME (First, Middle, Maiden Burnett")
<br />Carla Ann Teichmeier
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Wegert Cemetery
<br />,*[i. FC$E*AL Hf Ne lOrialAND MAIUNG ADDRESS (Street, City or Town, State)
<br />Alt aitti5 Ftunerl Home, 2929 S. Locust Street, Grand Island, Nebraska
<br />t8b. LICENSE NO.
<br />1495
<br />CITY / TOWN
<br />Grand Island
<br />146. RELATIONSHIP TO DECEDENT
<br />Spouse
<br />10c PATE (Mo:, Dry: Yr•)
<br />February 13, Z026 •
<br />..
<br />/ STATE
<br />Nebraska
<br />CAUSE OF DEATH (See Instructions and examples)
<br />13. PART I. EnlsrtM chain of *vents- diseases, NJurN., or complicationeaMt directly caused the Math. DO NOT enter terminal events such as cardiac arrest,
<br />. _. respiratory arrest, or ventricular fibrilla/Jon without showing the etiology. DO NOT ABBREVIATE. Enter only one cams on a NM. Add additional lines E necessary.
<br />IMMEDIATE CAUSE:
<br />MMMBDIATECANE f'b wl :0) coronary artery disease
<br />ieeteiar:eadNip:n rsutHtp;,''
<br />In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />s nuemi.IMNet conciliate,;M,.. b)
<br />, trikngteae;a }ee Mite"',..
<br />DUE TO; OR AS A CONSEQUENCE OF:
<br />ih+ewnt* multi.* In death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LABT .: d)
<br />APPROXIMATE -INTERVAL
<br />18. PART I :OT E:R. IGNI$$CANT CONDITIONSCondtttons contributing to the death but not resuttingdn the underlying cause given In PART 1.
<br />�1►ronic obstructive pulmonary disease
<br />24 IF FEMALE .
<br />,00*.r•fOitwlquup0 $1,:►
<br />❑ Pnprlardateftro�llydaath:<:
<br />f.
<br />0 Not pregnant, buil pregnant within 42 days of death
<br />0 Not pre0nent, but pregnant 43 days to 1 year before death
<br />dnkiewn N prstjnat t tNIhM 11M put year
<br />SJta DATE OFRAM' (tip,D y,Yr.)
<br />22d. INJURY AT WORK?
<br />❑YFs;GMO
<br />21e. MANNER OF DEATH
<br />® Natural ❑ HoaNcld0
<br />❑ AccMnt 0 Pending Investigation
<br />0 Suicide ❑ could not be ddtennined
<br />22b. TIME OF INJURY
<br />21b If TRANSPORTATION INJURY
<br />0 Driver/Operator
<br />CI Paeeenger
<br />❑ Pedestrian
<br />❑ Other (specify)
<br />anon toOath
<br />meat to
<br />19. WAS MRDICE)GAMINI
<br />OR confloNERCOWACTEtri
<br />❑ YES .';;111►xO .
<br />21c. WASAN A
<br />❑ YES
<br />21d. WERE AUTOPSY FINDINGS AVAI4,ABLE
<br />TO COMPLETE CAUeE OF DEATH?
<br />❑ YES. D NO
<br />22c. PLACE OF INJURY -At home, fart, street, facto-q, office building, construction site, etc. (EPfltify)..;.;,;..;:;:,
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />TKNN Of INJURY -:STREET & NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />February 8, 2026
<br />CITY/TOVYN STATE
<br />236. DATE SIGNED:(Mo., Day, Yr.)
<br />February 11. 2026
<br />23c. TIME OF DEATH
<br />11:52 AM
<br />224. Ts f:bon nr!sey IMOvAedgs, death occurred at the time, date and place
<br />end duet. the:defae(s) seed (Signature and Tula)
<br />Travis S. Hageman, MD
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c, PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEA*
<br />24d. TIME PRONOUNCO RifEAk
<br />24e. On sic beefy of examination and/or Imestigadon, In my (pbWn deal24 uty
<br />the tine, date and place and die to the ousels) elated. Planate* and MN)
<br />21L LIID TOBACCO LOSE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />I� YES ❑ :NO PROBABLY 0 UNKNOWN J 0 YES fin do
<br />�T NkMit TITLE AND AD.. SS OF CERTIFIER (Type or Print
<br />Travis S. Hageman, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />2$a. REGISTRAR'S SIGNATURE
<br />26b. WAS CONSENT GRANTEQt.
<br />Not Applicable it 26a Is NO I:t,'
<br />r:
<br />NO
<br />26b. DATE FILED BY REGISTRAR (MR.. Qays Yr:)
<br />February 19, 2028.
<br />
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