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<br />STATE OF NEBRASKA
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<br />EN TMS OF Y CARMES'TN# RAISED SEAL OF STATE OF NEBRASKA, IT, CERTIFIES THE DOCUMENT BELOW TO
<br />AMIE E COPY OP THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />UMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OFISStIAfNiCE
<br />LINCOLN;. NHEBRASKA .:
<br />1�1))�t�iilrlj1 44r 4.
<br />fur , ,(((i1�
<br />llirA"++ort,
<br />202J06320
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRA
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />31
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />CERTIFICATE OF DEATH
<br />1 IIECEDEN1$-NAMiw jFIrst,: : • Middle, Last, Suffix)
<br />}sham) it elal Xayarath.
<br />4, CITYA#dD;5 ATE{]R:TERRITQi2Y, OR FOREIGN COUNTRY OF BIRTH
<br />Laos
<br />9OCIAf SE URrrYNIUMBER
<br />452-#5 6547
<br />81i.:FACILITY.NAME.(If notIhatitutton, give street and number)
<br />°Nebtasko°;Medicine::
<br />ITY OR TOWN OF'DE4TH.(Include Zip Code)
<br />]Bi]a 6$118
<br />9a. RESIDENCE -STATE:-'.
<br />'Nebraska'
<br />9d ; STREET AND NUMBER:
<br />1;718 Alen GALIrt
<br />9b. COUNTY
<br />Hall
<br />5a'.AGE - Last`Birthday>
<br />(Yrs.)
<br />Sb.:UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />5c. UNDER 1 DAY
<br />22 0322'
<br />3: DATE OF DEATH ( o.r Day Ytr;)
<br />February 2+ 2022
<br />6.• DATE OF'BIRTH (Mo., Day; Yr.) ' <'
<br />MOS.
<br />DAYS
<br />8a. PLAGE OP. DEATH
<br />HOSPITAL ®,Inpatient
<br />'❑ EivOu patient
<br />0 DOA
<br />104.:MARfTAL:;ETATUWAT TIME•OF DEATH El Married 0 Never Married
<br />Martied''butseparated Q.Widotwed 0 Divorced 0 Unknown
<br />11 gAEHE
<br />Sieneih
<br />(First MI
<br />r:ath
<br />13. EVER IN VS ARMED'FORCES? Give' Oates of service if Yes.
<br />(Yes Na,'or .004 WO
<br />15:: ME11IOD;O
<br />#lanai
<br />Cremat)vn
<br />Relrlovpl
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />OTHER 0 Nursing Horne/LTC
<br />❑ Decedent's Home
<br />❑ Other.(Sp
<br />18d. COUNTY OF DEATH ••
<br />Douglas
<br />9e. APT. NO.
<br />9f. ZIP CODE..
<br />68803
<br />10b. NAME OF SPOUSE (First, Middle, Last, Suffix) if wife,
<br />Bountheng Chanhthaluxay
<br />12. MOTHER'S -NAME (First, Middle,
<br />Linla Xavarath.
<br />14a. INFORMANT -NAME
<br />Cy Xavarath
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16b. LICENSE NO.
<br />16d: CEMETERY, CREMATORY OR OTHER LOCATION •
<br />Westlawn Memorial Park Crematory
<br />17s, FUNERAL:HOME NAME.AND'MAILINO ADDRESS (Street, City or Town; State).
<br />ADfei Fun sral Hoe 11:23:W, 2nd, Grand Island, Nebraska
<br />1537
<br />CITY i TOWN
<br />Grand Island
<br />Ws. DATE (Mo.7 Day, Yr:)':
<br />March 4 2022
<br />Nebras
<br />ITU Zip Code
<br />68801
<br />CAUSE OF DEATH (See instructions: and examples)
<br />93. PARTI Enter the of Menne- 41tiaairm, injuries,or complications.that directly caused the death. DO NOT anter terminal events such as cardiac arrest,
<br />ryansst, or.ventricurar tibihjetion withoutshgwing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines N necessary.
<br />IMMEDIATE CAUSE:
<br />4) Hemolytic Uremic Syndrome
<br />'SerltiendaUy Ilet'Conditfoils; If .
<br />aify,)eadlegiUthe cause)fisted
<br />°MIMATE INTERVAL
<br />UE TO, OR AS A CONSEQUENCE OF:
<br />onset* death
<br />EeterthelJNbE l,1NGCAU5S
<br />(d16eaaa or ttijiii that initiated
<br />the:events resulting in daathl.:'
<br />5 TO,;OR AS A CONSEQUENCE OF:
<br />TO, OR AS A CONSEQUENCE OF:
<br />1*..pARt`I( fres SIGN(Fil
<br />Histoplasmo i5
<br />20.;IP FEMALE:,
<br />❑ Not prsgnantwfhtn pas
<br />❑' Pregnarnatama orasaitt: `
<br />r ktt prenn.gnadt but prsgnsnt v, grin 42 daya.ef death •
<br />�: Not pregnant but pregnant 43.deys to 1 year before death
<br />O, Unknown Wpregnamt wl6dn tt14 patttlear
<br />ANT'CONDITIONS-Conditions contributing to the death
<br />22a. DATE OF tNJURY (M Day Yr.)
<br />224 INJURY AT WORK?'
<br />©YES ( NO .;
<br />21a. MANNER OF DEATH
<br />El Natural ©Ho.Ittde
<br />0 Accident © Pending investrgetton
<br />0 Suicide ❑ could not be determined
<br />it net resulting in the:underlying cause given in PART I:.
<br />22b. TIME OF INJURY
<br />215. IF TRANSPORTATION INJURY
<br />❑ pr'ryed0perator
<br />peeaenger
<br />❑ Pedestrian
<br />0 Other (Specify)
<br />19. WAS MEDICALL EXAMINE(I
<br />OR CORONER CONTACTED
<br />• ❑ YES . _
<br />21c. WAS AN AUTOPSY MED?
<br />O YES:: NO : •
<br />21d. WERE AUTOPSY FiHD(NGS AVAl
<br />TO COMPLIETE CAUSE OP DEA'
<br />❑ YES ©U NO
<br />22c. PLACE OF IN iuR At home, farm, street, factory, office building, construction 919: 4444
<br />(Span
<br />22e'r DESCRIBE NOW INJURY OCCURRED
<br />22f:(.00ATIOR9FIN4URY :STREET&'NUMBER,APT.NO.
<br />24.;"DATE`t'DEATkOo., Day, Yr.)
<br />•
<br />February.24, 2022::..'
<br />CITYlyo WN
<br />STATE
<br />23b. DATE SIGNED (Mo., pay, Yr.) 23c. TIME OF DEATH
<br />POW -U *9 26;2022 09:00 PM
<br />4 the hast of t4Fy knowiedga, death occurred at the time, date and place
<br />nd d fo he>tapse(a) stated. (Signature and Title)
<br />ubra Snriivas MD'
<br />26 'DID TOBAOCO USE CONTRIBUTE TO THE DEATH?
<br />IYES ® NO Q PROBABLY. .0 UNKNOWN
<br />21,.NAME,TrittiA6 ADDRESS OF CERTIFIER (Type or Print
<br />Shubra Srinivas MO, .9$435 Nebraska Medical Center, Omaha, Nebraska, 68198
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />24b. TIME OF DEATH
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PROM IUNCEI.DEAD,
<br />`24e On (heAasis of examination andlor investigation,' in my soirees death ecOvna t. at
<br />: the time, date and place and due to the cause(s) stated (9tgndture add Tale).
<br />26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED?
<br />❑ YES El NO
<br />til
<br />fG*STRAR'S:SIGNATURE •
<br />26b. WAS CONSENT,GRANTED?
<br />Not Applicabie'1126a'1s NO: ❑YES
<br />28b. DATE FILED BY REGIS
<br />March 2,2022
<br />1o., Day, Yr.).
<br />
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