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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, IT
<br />CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DA/11OF2TE 019ISSUANCE
<br />9
<br />LINCOLN, NEBRASKA
<br />8
<br />t
<br />1
<br />I
<br />RUSSELL FOSLER
<br />2 ASSISTANT STATE REGISTRAR
<br />0 O DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE'' OF DEATH
<br />1. DECEDENTS -NAME (First, Middle, Last,
<br />Boundary Phommaravonges
<br />Suffix)
<br />2. SEX
<br />Male
<br />3. DATE OF DEATH (Mo., Day, Yr.)
<br />August 9, 2019
<br />4, CITY AND STATE OR TERRITORY. OR FOREIGN COUNTRY OF BIRTH
<br />Laos
<br />5a AGE - Last Slrthdsy iib. UNDER 1 YEAR
<br />(Yrs.)
<br />7. SOCIAL SECURITY NUMBER
<br />52,0-31-6134
<br />8b. FACILITY -NAME (If not Institution, give street and number)
<br />CHI Health St. Francis
<br />MOS.
<br />DAYS
<br />71
<br />Be. PLACE OF DEATH
<br />HOSPITAL ® Inpatient
<br />© EIVOutpatient
<br />O DOA
<br />6c. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />6. DATE OF BIRTH (Mak Day, Yr)
<br />June 20, 1948''
<br />OTHER 0 Nursing HomM.TC
<br />O Decedent's Home
<br />Other (Specify)
<br />Hospice Facility
<br />Sri, CITY OR TOWN OF DEATH (Include Zip Cods) (ted. COUNTY OF DEATH
<br />Grand Island 68803
<br />Se. RESIDENCE STATE I 8b. COUNTY Sc.CITY OR TOWN
<br />Nebraska Hall I Grand Island
<br />8d. STREET AND NUMBER
<br />831 East Sunset
<br />Hall
<br />pe. APT. NO. I If. ZIP CODE
<br />68801 9g. IMIDE CITr LIMITS
<br />YES n NO
<br />101. MARITAL STATUS AT TIME OF DEATH (j Married 0 Never Marred I job. NAME OF SPOUSE (First,
<br />0 Manana, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11. FATHER'S -NAME (First, Middle, Last, Suffix)
<br />Jon Phommaravongsa
<br />13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes.
<br />(Yes:, No, or two No
<br />15. METHOD OF DISPOSITION
<br />0 Burial fl Donation
<br />El Cremation 0 Entombment
<br />0 Removal El Other(Specify)
<br />Middle, Last, Suffix) If wife, give maiden name
<br />Teng Phonnan
<br />1 12. MOTHER'S•NAME (First, Middle, Maiden Surname)
<br />Lai Unknown
<br />14a. INFORMANT -NAME
<br />1 Seng Phommaravpnasi
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K. Hyronemus
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Central Nebraska Cremation Services
<br />17a.: FUNERAL ;HOME NAME AND MA LING ADDRESS (Street, City or Town, Stets)
<br />ADfe) Funeral Home, 1123 W. 2nd, Grand Island. Nebraska
<br />l 18b. LICENSE NO.
<br />1448
<br />CITY I TOWN
<br />Gibbon
<br />QAUSE OF DgATU(Serkir)Structlonst ane examDleg);
<br />a. PART i Enterths chainA 'Vents. -diseases, Injuries, or complltutions-that directly sauteed the death. DO NOT eller terminal *vents such as cardiac arrest.
<br />veep retory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional linos a necaeeary.
<br />IMMEDIATE CAUSE:
<br />IMMEDIATE CAUSE (Final a) Complications Of Craniotomy
<br />disease or condition resulting
<br />in dsath)
<br />Seewidialty Ilet cnnditknna if :••••
<br />any, UNding to tit causeMeted
<br />on line a. ...
<br />Enter the UNDERLYING CAUSE
<br />Geseese ra:InPG`feet Initial.
<br />event*
<br />...
<br />nls..wnes ea44litifi9 In death).ethiathl
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />1)subdural hematoma
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />e) Syncope And Collapse
<br />14b. RELATIONSHIP TO DECEDENT
<br />Daughter
<br />18c. DATE (Mo., Day, Yr.)
<br />August 17, 2019
<br />STATE
<br />Nebraska
<br />171k ZIP Code
<br />68801
<br />APPROXIMATE IN'!'@RVAi
<br />onset to death
<br />Minutes
<br />onset to death
<br />Hours
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting In the underlying cause given in PART I.
<br />Myocardial Infarction, Coronary artery disease, Diabetes Mellitus, End, Stage Renal Disease,
<br />20. IF.FEMALE:
<br />0 Not pregnane Within past year
<br />0 Pregnant at ams el Meth
<br />0 Net pregnant; but pregnant within 42 days of death
<br />0 Not pregnant, but pregn/Wee days to I year before death
<br />0 Unknewm If aefgnatwhNn the poet year
<br />22a. DATE OF INJURY (Mo., Day, Yr.)
<br />August 8 2019,
<br />22d. .INJURY ATWORIL3
<br />Q YES ENO
<br />21a. MANNER OF DEATH
<br />0 Natural 0 Homicide
<br />Accident 0 Pending Investigation
<br />0 Suicide 0 Could not be detsnnlned
<br />21b. IF TRANSPORTATION INJU
<br />0 Driver/Operator
<br />Passenger
<br />0Pedestrian
<br />0 Other (specify)
<br />19. WAS MEDICAL EXAMINER
<br />OR CORONER CONTACTED?
<br />O YES NO.
<br />21c. WAS AN AUTOPSY PERFORMED?
<br />0 YES NO
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?<
<br />EJ vas Oso
<br />22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, farm, street, factory, office building, construction site, etc. (Specify)
<br />04:00 PM ( St Francis ER parking lot
<br />22a. DESCRIBE HOW INJURY OCCURRED
<br />Patient was leaving ER after evaluation, and fell. He suffered a severe head -injury that precipitated neurosurgical;
<br />STATE
<br />Nebrgske
<br />22f. LOCATION OF INJURY - STREET & NUMBER APT,NO.
<br />2629 West FIldley, Granfi Island
<br />Ilia. DATE OF DEATH (Mo., Day, Yr)
<br />2019
<br />23b. DA TEAIGN TIED (Mo., Day, Yr.)
<br />September 10. 2019
<br />CITY/TOWN
<br />23c. TIME OF DEATH
<br />08:08 PM
<br />Rad. To the best of my knowledge, death occurred at the time, date and piece
<br />VW due to the aucu(s) stated. (Signature and Titin)
<br />,lav C. Anderson, MO
<br />4a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TiME OF DEATH
<br />ZiP CODE
<br />68803
<br />24d. TIME PRONOUNCED D
<br />24e. On the basis of examination and/or investigation, in my opinion death occurred at
<br />tits time, data and place and due to the ceoeMel stated. (signature and Tith)
<br />25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />0 YES 0 NO 0 PROBABLY fia UNKNOWN 0 YES ® NO
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Jay C, Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />2R :REGISTRAR'S SIGNATURE
<br />28b. WAS CONSENT GRANTED?
<br />Not Applicable If 26a Is NO O YES O NO
<br />28b. DATE FILED BY REGISTRAR(Me., Day, Yr.)
<br />September 10, 2019
<br />
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