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STATE OF NEBRASKA i pp FFxrft ;; ti WHEN '! THIS ' ^ COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS O FFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS PATE OF ISSUANCE 12/7/2016 LINCOLN NEBRASKA 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Bounsouay Boonie Saiyavongsa 'tK O 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 4, CITYAND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Laos 7. SOCIAL SECURITY NUMBER 586 -26 -3783 a 8c. CITY OR TOWN OF DEATH (Include Zip Code) • Grand Island 66803 9a. RESIDENCE -STATE V Nebraska a 9d. STREET AND NUMBER a 2519 West 11th Ave. 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married • ❑ Married, butseparated ❑ Widowed ❑ Divorced ❑ Unknown • 11. FATHER'S -NAME (First, Middle, Last, Suffix) , Chanephonq Unknown 12. MOTHER'S-NAME (First, Middle, Maiden Surname) Khamfoune Saiyavongsa E 22a. DATE OF INJURY (Mo., Day, Yr.) 0 .0 13. EVER IN U.S_ FORCES? Give dates of service if Yes. (Yes, No, or link.) NO 15. METHOD OF DISPOSITION ❑ Burial ❑ Donation ® Cremation ❑ Entombment ❑ Removal : ❑ Other (Specify) DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) .(disease of injuryltat Enitlsed, . Ake event resumngrn death) DUE TO, OR AS O S Q LAST 20. IFFEMALE: ❑ Not pregnant.Whhm past year ❑ Pregnant at time of death Not pregnant,. put pregnant within 42 days of death ❑ Net pregnant, put ptegnantas days to 1 year before death ❑ Unknown if pregnant within the past year W 2 2d. INJURY AT ORK? ❑ YES ❑ NO 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. . 2 o 2 NT OE OF DEATH (Mo., Day, Yr.) November 18, 2016 23b DATE SIGNED (Mo., Day, Yr.) November 21, 2016 9b. COUNTY Hall 16a. EMBALMER - SIGNATURE Christopher J. Loecker 16d. CEMETERY, CREMATORY OR OTHER LOCATION Central Nebraska Cremation Services CITY / TOWN Gibbon STATE Nebraska 17a. FUNERAL HOME NAME' AND MA LING ADDRESS (Street, City or Town, State) Agfel Funeral Home. 1123 W. 2nd, Grand Island, Nebraska CAUSE OF DEATH (See instructions and examples) Ea. PART 1. Enter the Chain of events - - diseases, injuries, or complications -that directly caused the death. DO NOT entertemitnal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line, Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Hepatocellular Carcinoma disease or condition resulting in death) onset to death 3 Weeks APPROXIMATE 'I NTERVAL Sequentially list conditions, if any, leading to the cause listed on line DUE TO, OR AS A CONSEQUENCE OF: b) onset to death A C N E UENCE OF: d) 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART 1. Hepatitis C 22b. TIME OF INJURY 22e. DESCRIBE HOW INJURY OCCURRED 21a. MANNER OF DEATH ® Natural ❑ Homicide ❑ Accident ❑ Pending Investigation ❑ Suicide Q Could not be determined 23c. TIME OF DEATH 02:45 AM 3d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Thoras F. Werner, MD 25. D#D TOBACCO USE CONTRIBUTE TO THE DEATH? Q YES El NO ❑ PROBABLY ❑ UNKNOWN 14a. INFORMANT -NAME Thonglay Saiyavongsa CITY /TOWN 5a. AGE - Last Birthday (Yrs.) 61 6b. UNDER 1 YEAR M OS. DAYS 2. SEX Male 5c. UNDER 1 DAY HOURS MINS. 3. DATE OF DEATH (Mo., Day, Yr.) November 18, 2016 6. DATE OF BIRTH (f40., Day, Yr.) December 13, 1954 8a. PLACE OF DEATH HOSPITAL © Inpatient ❑ ER/Outpatient Q DOA OTHER ❑ Nursing Home/LTC ❑ Decedent's Home ❑ Other (Specify) Q Hospice Facility 8d. COUNTY OF DEATH Hall 9c. CITY OR TOWN Grand Island 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Thonglay Phllathonq 9e. APT. NO. 16b. `LICENSE NO. 1421 21b. IF TRANSPORTATION INJURY 0 Driver /Operator ❑ Passenger ❑ pedestrian 0 Other(Specify) 9f. ZIP CODE 68803 STATE U z O $ K z o F V 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? El YES QNO 9g. INSIDE CITY LIMITS ® YES ❑ NO 14b. RELATIONSHIP TO DECEDENT Wife 16c. DATE (Mo., Days Yr.) November 26, 2016 17b,ZipCode 68801 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES 5i1 NO 21c. WAS AN AUTOPSY PERFORMED? ❑ YES 0 N 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH ? ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 21P CODE 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.)j 24d. TIME PRONOUNCED DEAD `. 24e. On the basis of examination and /or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO d YES 7. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Thomas F. Werner, MD, 810 North Diers Avenue, Grand Island, Nebraska, 68803 28a, REGISTRAR'S S IGNATURE I a j 28b. DATE FILED BY REGISTRAR (Mo., Da December 1, 2016 201608541 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH ate STANLEY S. COOPER ASSISTANT STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES