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M = D M CA <br />n n A <br />� 11 <br />7 <br />WHEN TENS COPYCARRES TIE RAISED SEAL OF THE NEBRASKA HEA <br />SYSiEA4 R CERTIIFAES THE BELOW TO BE A TRUE COPY OF THE ORIG <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL ST/ <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />U LACE <br />Std <br />L 7 <br />G7 <br />4 <br />m <br />��fi •r-• <br />o -v <br />o <br />r ++ <br />�g <br />DATE OF /SSA �- <br />12/8/2003 <br />LINCOLN, NEBRASKA 200501390 HEALit Ahl@ � F <br />ff IS <br />i <br />En <br />� cr> <br />CD -I <br />C D <br />� m <br />< o <br />o T <br />r <br />1K 4! <br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERYI4iF7Nld1E A_ SF PPORT <br />vrrAL STATISTICS <br />CERTIFICATE OF DEATH __ 03 13676 <br />1. DECEDENT -NAME FIRST MIDDLE LAST <br />2. SEX I <br />3. DATE OF DEATH /Month. Day. Year) <br />Jerry John Stoltenberg <br />Male <br />November 25, 2003 <br />4. CITY AND STATE OF BIRTH (Ifnof in U.S.A.. name country) <br />Sa. AGE - Last Birthday <br />UNDER i YEAR <br />UNDER 1 DAY <br />6. DATE OF BIRTH (Month. Day. Year) <br />Grand Island, Nebraska <br />(Yrri 55 <br />ii MOS. I DAYS <br />Sc. HO MINS. <br />June 11, 1948 <br />7. SOCIAL SECURTIY NUMBER <br />8a. PLACE OF DEATH <br />505 -64 -1190 <br />HOS Inpatient OTHER: <br />HOSPITAL ® Nursing Home <br />-- ❑ <br />❑ ER Outpatient ❑ Residence <br />8b. FACILITY -Name (ll not inst,40ort give street and number) <br />Good Samaritan Hospital <br />❑ DOA ❑ Other (Specav, <br />8c. CITY. TOWN OR LOCATION OF DEATH <br />Bd. INSIDE CITY LIMITS <br />fie. COUNTY OF DEATH <br />Kearney, 68847 <br />Yes ® No ❑ <br />Buffalo <br />ga. RESIDENCE -STATE <br />9b. COUNTY <br />9c. CITY. TOWN OR LOCATION <br />9d. STREET AND NUMBER (IrlcludingZip Code) <br />9e. INSIDE CITY LIMITS <br />Nebraska <br />Hall <br />Grand Island <br />1516 =Post -Place 68801 <br />Yea 21 No ❑ <br />10. RACE - (e.g., White. Black. American Indian. <br />11. ANCESTRY fe.g.. Italian. Mexican, German, etc) <br />12 X] MARRIED ❑ WIDOWED <br />13. NAME OF SPOUSE /it wife, give maiden name/ <br />etc.) (Specify) White <br />(sP"Y) German - <br />NEVER DIVORCED <br />K Kirkland <br />14a. USUAL OCCUPATION (Give kind of work done dung most <br />14b. KIND OF BUSINESS INDUSTRY <br />15. EDUCATION (Specify only highest grade completed) <br />of working life, even if retired) Owner /operator <br />Cabinet building <br />Elementary or Serary (0.12) College 11 -4 or 5 -1 <br />L_ <br />16, FATHER -NAME FIRST MIDDLE LAST <br />17. MOTHER FIRST MIDDLE MAIDEN SURNAME <br />Elmer Stoltenberg <br />Maybelle Bergholz <br />18. WAS DECEASED EVER IN U.S. ARMED FORCES? <br />19a. INFORMANT -NAME <br />(Yes. no "Ink.) (If yes. give war and dates of services) <br />.Yes'/ 9 -29 -67 to 9 -28 -73 <br />Kimberly Stoltenberg <br />1516 Post Place Grand Island, Nebraska 68801 <br />1 20. EMBALMER - SIGNATURE 8 LICENSE NO. <br />21 a. METHOD OF DISPOSITION <br />21b. DATE <br />21c. CEMETERY OR CREMATORY NAME <br />not embalmed <br />❑ Burial ❑Removal <br />11- -26 -03 <br />Cehtral Nebraska Cremation Services <br />22a. FUNERAL HOME -NAME <br />21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE <br />Curran Funeral Chapel <br />x❑ cremation ❑ Donation <br />Gibbon, Nebraska 68840 <br />22b. FUNERAL HOME ADDRESS ISTREET OR R.F.D. NO.. CITY OR TOWN. STATE. ZIP) <br />3005 South Locust Street Grand Island, Nebraska 68801 <br />23. IMMEDIATE CAUS LATER ONLY ONE CAUSE PER LINE FOR (al. Ibl, AND (c)) I Interval between onset and death <br />PAR')I <br />DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and death <br />i <br />e Ibl I <br />DUE TO, OR AS A CONSEQUENCE OF: I Interval between onset and death <br />I <br />(c) <br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing to the death but not related PART <br />III IF FEMALE- WAS THERE A <br />AUTOPSY <br />25. WAS CASE REFERRED TO MEDICAL <br />PART PREGNANCY <br />11 <br />IN THE PAST 3 MONTHS? <br />121 <br />EXAMINER OR CORONER? <br />(Ages <br />10 -54) Yes No <br />Yes 171 f X <br />Yes No <br />26a. <br />26b. DATE OF INJURY (MO.. Day Yr.) <br />26c. HOUR OF INJURY <br />26d. DESCRIBE HOW INJURY OCCURRED <br />Accident Undetermined <br />M <br />Suicide Pending <br />26e. INJURY AT WORK <br />26f. PLACE QF, INJURY - At tame, farm, street. factory <br />office uddmg, etc. /Specify/ <br />26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE <br />Homicide Investigation <br />❑❑ <br />Yes No ❑ <br />27a. DATE OF DEATH (Mo.. Day. Yr.) <br />28a. DATE SIGNED (Mo.. Day. Yr) <br />28b. TIME OF DEATH <br />= <br />November 25, 2003 <br />>� <br />M <br />N <br />i <br />In <br />27b. SIGNED (Mo.. Day. Yr.) <br />27c. TIME OF DEATH <br />2Bc. PRONOUNCED DEAD (Mo.. Day, Yr.) <br />28d. PRONOUNCED DEAD (Hourl <br />DATE <br />IBS C,v OU <br />� /- M <br />�� <br />M <br />° <br />27d. To the best of my knowle�deathcurred time, dat place and due to the <br />causefs) stated. <br />28e. On the basis of examination and,or investigation, in my opinion death occurred at <br />the time, date and place and due to the cause(s) stated. <br />< <br />6 <br />~ ° a <br />(Signature and Title) <br />1111-iSignalture and Title) ► <br />29. DID TOBACCO USE CONTRIB TE TO THE DEATH? 3Q <br />ORGAN OR TISSUE DONATION BEEN CONSIDERED? <br />30b WAS CONSENT GRANTED? <br />❑ YES TO E- UNKNOWN <br />YES ❑ NO <br />� YES ❑ NO <br />31. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Pdnt) <br />E.A. Badejo, M.D. 3219 Central Avenue Suite 103 Kearney, Nebraska. 68847 <br />It 41! <br />32a. REGISTRAR <br />32b. DATE FILED BY REGISTRAR (Mo.. Day. Yr.) <br />DEC 5 2003 <br />n v <br />Lot Eight (8), Heritage Acres Subdivision, the City of Grand Island, Hall County, NE <br />0 <br />(V <br />0 <br />0 <br />C_n <br />0 <br />C13 <br />0 <br />