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<br />)c_ STATE OF NEBRASKA
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<br />THEN THIS COPYCA.RRIE$ THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO.
<br />E A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />U, MAN SERVICES V17`�QL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />/02201
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR .:
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />EDENa! NAb1E _tFirst •;Middle, Last, Suffix)
<br />?!130#tisalle
<br />T SQCIALSECURITYN.000ER
<br />524-27-0212
<br />Se. AGE - Last:Birthday
<br />(Yrs.),
<br />Sc.. CITY OR T Wi OF Iii?ATH (inetuile Zip Code)
<br />Grand Island 68801
<br />a, RESIDENCE STA
<br />8i1 STREETAND NI1MHE t
<br />11621 WindlsorRoad':
<br />Sb UNDER 1 YEAR
<br />MOS.
<br />DAYS
<br />Sa. PLACE OP DEATH s .
<br />Ho$PITAL . ❑. Inpgi ent
<br />.�...« ❑ ER/Outpatlent
<br />❑ DOA
<br />913. COUNTY
<br />Hall
<br />OS. RITAL STATUS AY' •Ni.OF DEATH 0 Married Never Married
<br />•sided,idowed:.,.❑ Divorced 0 Unknown
<br />11 'FAT#4!
<br />3leflq,
<br />13 <EVERiN U $ AMMED FORCE$?'.Give'dates.of service if Yes:
<br />lYee,No;dr111*)NO
<br />IE:; METHOD OF DISPOSITION
<br />17a : FUNEltA4;HOME NAME ANb
<br />kptel Fun rel Houle 1'12
<br />X18; PART I, Enter
<br />9c. CITY OR TOWN
<br />Grand Island
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />HOURS
<br />MINS.
<br />3. DATE
<br />Febr(i
<br />2 09807:
<br />DEATH (Mo., Day
<br />ry 3::>Zfl22:::::>: ,...
<br />OTHER El Nursing Hone/LTC
<br />® Decedent`s:
<br />. ❑ Other (Specify)
<br />r
<br />I8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT, NO.
<br />9f. ZIP CODE
<br />68801
<br />1ob. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife,
<br />12 MOTHERS.NAME (First, Middle,
<br />}ouchanh` Unknown
<br />14a. INFORMANT -NAME
<br />Kelly Phothisane
<br />16a. EMBALMER -SIGNATURE
<br />Gwen K, Hyronemus
<br />16d. CEMETERY, CREMATORY OR OTHER LOCA1
<br />Westlawn Memorial Park Crematory
<br />AILING;ADDRESS (Street, City or Town, State),
<br />2nd, Grand Island, Nebraska
<br />16b. LICENSE NO.
<br />1448
<br />CITY / TOWN
<br />Grand Island
<br />'�rrt"I' IiMITS;;
<br />NO;....
<br />CAUSE OF DEATH (Se
<br />e ldkktrudtion$ and examples)
<br />haln of'events 411isashInjuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />rgr:Ventricutarnnen ladonwithout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.
<br />IMMEDIATE' CAUSE:
<br />FjnN a) metastatic hepatocellular carcinoma
<br />eIIy:flat.cortdlttc
<br />aey, 4.4.410910.9*.oatiaa.
<br />E;TO, OR AS A CONSEQUENCE OF:
<br />ronlehepatitis B
<br />fora rite UNDEt LTlq
<br />even ceaitiddc to it
<br />the
<br />Is;
<br />TOr`OR'AS A CONSEQUENCE OF:
<br />(h)
<br />7Q,;ORM A CONSEQUENCE OF:
<br />•
<br />& PART li OTIlER SIGNIFICANT CONDITIONS.Conditions contributing to the thiatit but net re
<br />ejlen4004so0hB610Sl varicles '
<br />of death:
<br />but }laegndnt vrtbdn 42;deys Of death
<br />ignantea days tort yearbefore death
<br />Oil iNJURY:AT WORK?,.
<br />F?'
<br />21a. MANNER OF DEATH
<br />E Natural ❑ Homicide
<br />0 Accident 0 Pending investigation
<br />0 Suicide 0 Could not be determined
<br />'the underlying cause given in PART I.
<br />22b. TIME OF INJURY
<br />22c. PLACE OF.INJURY..At
<br />RISE NOW INJURY OCCURRED
<br />f' LOCATION OP INJ11ftY
<br />& NUMBER, APT.NO.
<br />i:11ATE OF DEATN.;(Mo., Day,, Yr.)
<br />February 3, 2022 , .. '•
<br />CITYfTOWN
<br />2313. DAN $(t9NED (Mo., Day; Yr.) 23c. TIME OF DEATH
<br />Feb -aril3022 07:09 AM
<br />ra;tfre i?pii{ eiN rknowtedge,deetii occurred at the time, date and place
<br />and duet44fee:esuseie?elated: (Signature and Tide).
<br />e MCOGh81ld MD
<br />BUTE;TO THE DEATH?
<br />PR08ABLY El UNKNOWN
<br />21b. IF: TRANSPORTATION INJURY
<br />9 DiiNer/Operator
<br />,9 Pae'senger
<br />Q Pedestrian •
<br />❑ Other (Specify)
<br />21c. WAS AN ADSPSY/
<br />❑xaSta
<br />21d WERBAUT{7PSYSNIN1I/3$A uLABI.,
<br />TO COMPLETE'GAU$E:OFDEATH? .:
<br />0
<br />home,;farmStreet, factory, office building, con
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TI
<br />Dl
<br />24c.,PRONOUNCED DEAD (Mo., Day, Yr.)
<br />PRONOUNOED DEAD...
<br />24e `:bR Sita Imala of examination and/or lnvastmation, in my mantel's d__,
<br />''still: ti fie, date and place and due to the cause(s)'etated. (signadae
<br />BACGO USE;GO� NtTRI 26a. HAS ORGAN AOR TissuEDDNATIDNSEEN CONSIDERED?
<br />❑ YES _ e
<br />TITLEAND AD #R $O.Ot.CERTIFIER (Type or Print
<br />Mi onald; IVtC} 800`N Alpha St, Grand Island, Nebraska, 68:+
<br />26b. WAS CONSENT GRAl
<br />Not Applicable if 26ais.NOi,
<br />28b. DATE FILED BY REGISTRAR (Mo. Day, Yr.)
<br />February 8, 2022 :'
<br />
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