201803718 - Laserfiche WebLink

Browse

= *om t, ' � !ti+ "t^ "i;' r., ' .f N /6 1V,)1 STATE OF NEBRASKA ' `''` 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 OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 4/4/2018 LINCOLN, NEBRASKA 201803718 STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH STANLEY COOPER ASSISTA STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Dua Tran Nguyen 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH Vietnam 7. SOCIAL SECURITY NUMBER 438 -73- 5.917 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 9a. RESIDENCE ,STATE Nebraska 9d. STREET AND NUMBER 303 E 18th St 10a, MARITAL STATUSAT TIME OF DEATH ® Married ❑ Never Married 0 Married, but separated ❑ Widowed ❑ Divorced ❑ Unknown 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO 15. METHOD OF DISPOSITION ❑ 0-Donation ® Cremation ❑ Entombment ❑,:Removal ❑ Other (Specify) 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Livingston- Sondermann Funeral Home. 601 N. Webb Road. Grand Island, Nebraska 18. PART II. OTHER SIGNIFICANT CONDITIONS- Conditions contributing to the death but not resulting in the underlying cause given in PART I. 20. FEMALE: Not pregnantwithm past year ❑. Pregnant at time of death ❑ Not pregnant, but pregnant within 42 days of death : 0 , Not pregnant but pregnant 43 days to 1 year before death ❑_ 4nknownif pregnant within the past year 22a. DATE OF INJURY (Mo., Day, Yr.) 22d,>)N JURY. ATS yVQRKY..:. ❑YES ❑NO 23a. DATE OF DEATH (Mo., Day, Yr.) March 21, :2018 9b. COUNTY Hall 22b. TIME OF INJURY .0 8 t 2313, DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH <; g u z March 23, 2018 10:07 AM B 4 • O 3d. To the best of my knowledge, death occurred at the time, date and place • .-1 and due to the cause(s) stated. (Signature and Title) Dav Crockett, MD 25. DI.D TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES 10 NO ❑ PROBABLY ❑ UNKNOWN 1 28a, R EG( S T R R 'SSIGNAtURE , 6 Se. AGE - Last Birthday (Yrs.) 50 14a. INFORMANT -NAME Dzunci Nguyen 16a. EMBALMER - SIGNATURE Matthew T. Myers 21a. MANNER OF DEATH Natural ❑ Homicide 0 Accident ❑ Pending Investigation ❑ Suicide 4..� Could not be determined 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? ❑ YES 7 NO Sb. UNDER 1 YEAR MOS. 9c. CITY OR TOWN Grand Island DAYS 2. SEX Female Sc. UNDER 1 DAY HOURS MINS. 9e. APT. NO. { 9f. ZIP CODE 68801 16b. LICENSE NO. 1411 24a. DATE SIGNED (Mo., Day, Yr.) 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 3. DATE OF DEATH (Mo., Day, Yr.) March 21, 2018 6. DATE OF BIRTH (Mo., November 11. 1967 tf,Yr.) 8a. PLACE OF DEATH HOSPITAL ❑ Inpatient ER/Outpatient ❑ DOA OTHER ❑ Nursing Home /LTC ❑ Decedent's Home ❑ Other (Specify) Hospice Facility 8d. COUNTY OF DEATH Hall 1013. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name IDzung Nguyen 99. INSIDE CITY LIMITS ® YES ❑ NO 11. FATHER'S-NAME. (First, Middle, Last, Suffix) Day Tran 12. MOTHER'S -NAME (First, Middle, Maiden Surname) A Nguyen Spouse . 16c. DATE (MO., Day, Yr,), March 24, 2018 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN Westlawn Cemetery Grand Island STATE Nebraska 1Tb. Zip Code 68803 CAUSE OF DEATH. (See instructions and examples) 1e. PART L Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal 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) Acute Respiratory Failure disease or condition resulting APPROXIMATE INTERVAL onset to death 1 Day in death) Sequentially list condihons, If eny, leading to the:causs listed n • DUE TO, OR AS A CONSEQUENCE OF: b)Metastatic Gastric Cancer onset to death 3 Months Enter the UNDERLYING CAUSE (disease Of injury that initiated s . ... - the.evemsxespffing m ath) •:; LAST DUE TO, OR AS A CONSEQUENCE OF: c) onset to death DUE TO, OR AS A CONSEQUENCE OF: d) 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES El No 21b IF TRANSPORTATION INJUR 0 Driver /Operator ❑ Passenger ❑ Pedestrian 0 Other (Specify) 21c. WAS AN AUTOPSY PERFORMED? ❑ YES ® NO 21d. WERE AUTOPSY FINDINGS AVAILABL TO COMPLETE CAi1SE O) DEATlt ❑ YES ❑ NO 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE 24b. TIME OF DEATH 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 ❑ YES NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print) David Crockett, MD, 2620 W Faidley Avenue, Grand Island, Nebraska, 68803 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) April 2, 2018