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<br />WHEN THIS COPY ` CARRIES THE RAISED SEAL OF THE STATE OF NEBRASKA, I1
<br />CE•RTf 1ES• THE DOCUMENT BELOW TO BE .A TRUE COPY !7F THE ORIGINAL RECORD
<br />ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL
<br />RECORD$ OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE _.
<br />6/17/2021
<br />LINCOLN, NEBRASKA
<br />m_
<br />d
<br />4,
<br />1r0ECEDENTS-NAME (First, Middle,
<br />Phlmmasone •Sengsom
<br />4. CITY ANDSTATE OR TERRI
<br />Laos
<br />7 SOCIALS URI'I' "'NUMBER
<br />5,53.87 2083
<br />8b. FACILITY -NAM
<br />VNMC
<br />202206832
<br />.Gt4 1 ,e2...
<br />SARAH BOHNENKAMP 7
<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 />Last, Suffix);
<br />Y, OR FOREIGN COUNTRY OF BIRTH
<br />Of not Institution, give street and number)
<br />8c CITY OR TQWN OF DEATH (Include Zip Code)
<br />Qn Iia 68198
<br />9a. RESIDENCE -STATE
<br />Nebraska
<br />9di,STREET/ I ID NUMBER
<br />'08 Seal Street
<br />8a. AGE . Last Birthday
<br />(Yrs.)
<br />65:.
<br />8b. UNDER 1 YEAR
<br />2. SEX
<br />Female
<br />8c. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />8a. PLACE OF DEATH
<br />HOSPITAL Inpatient
<br />❑ ER/Outpatient
<br />0 DOA'
<br />9b. COUNTY
<br />Hall
<br />1O8. MARITAL STATES AT TIME OF DEATH E Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />11 FATHER'S -NAME (Flret, Middle; Last, Suffix)
<br />'fan Kochanhthala
<br />13, EVER IN V.8. ARMED FORCES?Give dates of service if Yes.
<br />(Yes, No, or Unk.) No
<br />15. METHOD OF DISPOSITION
<br />Burlal ❑ Donation
<br />Cremation Q Entombment
<br />❑ Removal ❑ Otter (Specify)
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />21 07665
<br />3. DATE OF DEATH .(MO„ #lay; Yr.
<br />May 28, 2021
<br />6. DATE OF BIRTH (Mo., Day, Yr.i.'
<br />October40, 1::955::>'
<br />OTHER 0 Nursing Home/LTC
<br />❑ Decedent's Have
<br />❑ Other (Specify)
<br />I8d. COUNTY OF DEATH
<br />Douglas
<br />9e. APT. NO.
<br />i0b. NAME OF SPOUSE (First, Middle,
<br />Somsay Sengsom
<br />14a. INFORMANT -NAME
<br />Somsay Sengsom
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />9f. ZIP CODE
<br />68801
<br />tI i NS1DE CITY UNITS
<br />S YEE CI NO
<br />12, MOTHER'S -NAME (First, Middle,
<br />Oudom Phommasack
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION
<br />Westlawn Memorial Park Crematory
<br />17a FUNERAI.;HOME NAME AND MAILING ADDRESS (Street, City or Town, State)
<br />ADf'el Funeral Home, 1123 W. 2nd, Grand Island; Nebraska
<br />16b. LICENSE NO.
<br />1537
<br />CITY / TOWN
<br />Grand Island
<br />Maiden
<br />14b. RELATIONSHIP TODECEDENT
<br />Spouse
<br />16c. DATE:(MQ., Day, Yr:)
<br />June 5, 2021
<br />STATE
<br />Nebra
<br />ii!!;:it8801mr.
<br />CAUSE OF DEATH (Se
<br />e Instructions and examples)
<br />18. PART I. Enter the chain of events- eeseeses, injuries, or complications4hat directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular f brilladon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a em. Add additional !Irak 8 necese
<br />IMMEDIATE CAUSE:
<br />iMIFTEDIAI* cAAtlsE iFlnal a) Colonic Ischemia
<br />dseeeaorcopdINDnresu$hig�.
<br />mdeathl DUE TO, OR AS A CONSEQUENCE OF:
<br />sequentially pet conditions, if b) Dilated Colon
<br />any, leading to the cause limed
<br />on ane
<br />DUE; TO, OR A8 A CONSEQUENCE OF;
<br />Etlt rtaetlNDERLYII4GcAUSE c)Adyna'mic Ileus
<br />(disevee or Ir4iitythat inkiated
<br />the events re5uiting in 4eath)
<br />LAST
<br />DUE TO, OR A8 A CONSEQUENCE OF:
<br />d)
<br />onset to death
<br />3 Days
<br />1S SART.1. OTHER SIGNIFICANT CONDmON8-Condition contributing to the death but not resulting in the underlying cause given In PART I.
<br />Disseminated Intravascular Coagulation, Heart Failure, Fluid Overload,' Renal Failure, Lactic Acidosis, Septic Shock
<br />20. IF.FEMALEs:.
<br />Notpregnant wltitin pester
<br />pregaent anima ordeal
<br />❑' Not pregiapt, but pragnaM within 42 days of death
<br />❑ Not pregnant, but pregnant 43 days to 1 year before death
<br />a-Unknown ti pregnant within the past year
<br />21a. MANNEROF DEATH
<br />RI Natural ❑ Hominids
<br />❑.Accident ❑ Paroling hwestlgstion
<br />❑ Suicide ❑ Could not be determined
<br />21b. IF TRANSPORTATION INJURY
<br />❑ Driver/Operator
<br />Passenger
<br />❑ Pedestrian
<br />❑ Other (Spongy)
<br />onset to death
<br />19. WAS MEDICAL. EXAMINER
<br />OR COacifi CONTACTED?::
<br />❑ YES ® NO
<br />PST:PERFORMED?
<br />21d. WERE AUTOPSY FINDINGS AVAILABLE
<br />TO COMPLETE CAUSE OF DEATH?
<br />❑YES DU NO..
<br />'tt
<br />4,
<br />220DATE OFINJURY (Mu„ Day, Yr.)
<br />22d. IiINJURY AT WORK?
<br />❑ YES NO
<br />22b. TIME OF INJURY
<br />22c. PLACE: OF INJURY•At
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />22I ;LOdAiidN OF INJURY SIRE -Era NUMBER, APT.NO.
<br />23a. DATE OF DEATH (Mo., Day, Yr.)
<br />May 28, 2021
<br />23b. DATE SIGNED (Mo., Day, Yr.)
<br />June 2, 2021
<br />3.
<br />0.
<br />me, farm, street, factory, office building, cons
<br />CITY/TON
<br />23c. TIME OF DEATH
<br />08:44 PM
<br />YO The biet uf:n V knowledge, death occurred at the time, date and place
<br />ai l dee tehe cauae(e) sued. (Signature and Title)
<br />Shaun L. Thompson, MD
<br />28 oto TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />)VAS ®NO ❑ PROBABLY ❑ UNKNOWN
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />2IP CODE
<br />24b. TIME OF DEATH
<br />24d. TIME UNCEP D
<br />2444n ata basis of examination angor investigation, in opindat eteei44erret.ie
<br />Ela tkae, date and place and due to the cause(s) stated. (Signature alt Olde)'
<br />26a. HAS ORGAN OR TISSUE DOItATION. BEEN CONSIDERED?
<br />0 YES I'$
<br />NAME,TME AND ADDRESS OF CERTIFIER (Type or Print
<br />Shaun L. Thompson, MD, 984455 Nebraska Medical Center, Omaha.; _• ska,
<br />26b. WAS CONSENT GRANTED?
<br />Not Appllcable'If 28a is NO ; ❑ YES:.
<br />D N0
<br />27
<br />198'
<br />28a. REGISTRAR'S SIGNATURE
<br />28b. DATE FILED BY REGISTRAR (Mo., Day Yr.)
<br />June 11, 2021
<br />
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