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STATE OF NEBRASKA 1411,4 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 6/22/2018 votio,:ty t t` cwt:: t't- LINCOLN, NEBRASKA ASSISTA(1JIf STATE REGISTRAR DEPARTMENT HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH 07744 Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the county court in the county where the decedent resided at the time of death. 1. DECEDENT'S -NAME (First, Middle, Last, Suffix) Patthana NMN Manivong 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) , June 14, 2018 4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Laos (Yrs.) 50 MOS. DAYS HOURS MINS. March 2, 1968 7. SOCIAL SECURITY NUMBER 410-35-4409 8a. PLACE OF DEATH HOSPITAL E Inpatient OTHER ❑ Nursing Home/LTC 0 Hospice Facility 8b. FACILITY -NAME (If not Institution, give street and number) CHI Health St. Francis 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 418 E. Oklahoma Avenue 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS E YES ❑ NO 10a. MARITAL STATUS AT TIME OF DEATH E Married ❑ Never Married ❑ Married, but separated El Widowed ❑ Divorced ❑ Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Thonglam Sombounsouk 11. FATHER'S -NAME (First, Middle, Last, Suffix) Heuanq Manivonq 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Khiene Phetyim 13, EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or Unk.) NO 14a. INFORMANT -NAME }I Kon Manivonq i 14b. RELATIONSHIP TO DECEDENT Son 15. METHOD OF DISPOSITION ❑ Burial 0 Donation 16a. EMBALMER -SIGNATURE Chris McCoy 16b. LICENSE NO. 1191 16c. DATE (Mo., Day, Yr.) June 16, 2018 ® Cremation ❑Entombment El Removal 0 Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY I TOWN STATE Westlawn Memorial Park Crematory Grand Island Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) Aofel Funeral Home. 1123 W. 2nd. Grand Island. Nebraska 17b. Zip Code 68801 CAUSE OF DEATH (See instructions and examples) It. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL 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 onset to death Unknown in death) DUE TO, OR AS A CONSEQUENCE OF: Sequentially tel conditions, if b) Pulmonary Metastases any, leading to the Cause listed on line a. onset to death Unknown DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Colon Carcinoma (disease or injury that initiated:. onset to death Unknown the events rsaulting In death) :. DUE TO, OR AS A CONSEQUENCE OF: LAST' d) onset to death 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Non -ischemic Cardiomyopathy 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑YES RENO 20. IF FEMALE: ❑ Not pregnant within past year El Pregnant at time of death 21a. MANNER OF DEATH E Natural 0 Homicide ❑ Accident El Pending Investigation 21b. IF TRANSPORTATION INJURY ❑ Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? 0 YES ENO 0 Not pregnant, but pregnant within 42 days of death 0 Not pregnant, butt pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year Suicide 0 Could not be determined ❑;Pedestrian ❑ Other (Speedy) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES El NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? ❑YES ONO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE To be completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) June 14, 2018 To be completed by CORONER'S PHYSICIAN or. COUNTY ATTORNEY. ONLY 248. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) June 15, 2018 23c. TIME OF DEATH 03:47 AM z4c. in UNOUlrCED DEAD (Mo., Day, Yr.' 24d. Tit: E rrIONOUNCEO DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Manoi;Suryanarayanan, MD 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) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? El YES E' NO ❑ PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR ISSUE DONATION BEEN CONSIDERED? ❑ YES ENO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES 0 NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Manoj Suryanarayanan, MD, 2620 W Faidley Ave, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE / A _ �/7 _ _ 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.) June 18, 2018