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STATE OF NEBRASKA
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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO
<br />BEA TRUE COPY OP THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />ATE 00 ISSUANCE
<br />11/9/2021
<br />LINCOLN, NEBRASKA
<br />202402994
<br />rt*
<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 />1. DECEDENTS -NAME (Eliot, Middle, Last, Suffix)
<br />Vankham< Soutmahavong
<br />4. CITY ANDSTATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH
<br />:7. SOCIAL SECURITY NUMBER
<br />451-49-3450
<br />5t*, AGE - LastBitthday
<br />(Yrs.).
<br />8
<br />a
<br />4
<br />Bb. FACILITY -NAME (If ltiot Institution, give street and number)
<br />519 N. White Avenue
<br />Sc.: CITY OR TOWN OF DEATH (Include Zip Code)
<br />Grand Island 48803
<br />9t*. RESIDENCE -STATE
<br />Nebraska
<br />941..S'rREET. uit itiMBE'f;:::.
<br />519 N White Avenue.
<br />9b. COUNTY
<br />Hall
<br />10a MARITALSTATUSAT TIME OF DEATH ® Married 0 Never Married
<br />0 Married, but separated 0 Widowed 0 Divorced 0 Unknown
<br />;t1. FATHER S (i)AME #Fif t Middle, Last, Suffix)
<br />tengbout; Boutrrtahavonp
<br />13. EVER* U.S ARMED'FORCES? Give dates of service if Yes.
<br />(Yes, No, or Link.) No
<br />IL METHOD OF DISPOSITION
<br />❑: Bur)N O Denabon
<br />CrsmatIon ❑Entombment
<br />[ 'Removal" (Specify)
<br />Sb UNDER 1 YEAR
<br />2. SEX
<br />Male
<br />Sc. UNDER 1 DAY
<br />MOS.
<br />DAYS
<br />Se. PLACE OF'DEATH
<br />HOSy SPITAL ] Inpatient
<br />❑ ER/Ou patient
<br />0 DOA
<br />9c. CITY OR TOWN
<br />Grand Island
<br />HOURS
<br />MINS.
<br />3. DATE OF DEATH PA', Ray;
<br />October 3& 20.21
<br />8. DATE OF BIRTH (Mo., Day;Yr:
<br />June 3, 1947
<br />OTHER 0 Nursing Home/LTC
<br />Decedent's Home
<br />L] Other (Specify)
<br />8d. COUNTY OF DEATH
<br />Hall
<br />9e. APT. NO.
<br />W. ZIP CODE
<br />68803
<br />lab. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, gi
<br />Ouphayvanh Nanthaveth
<br />NBIDE it
<br />ITYEs
<br />[ 12. MOTHERS44AME (First, Middle, Maiden Surname)
<br />Bovapha Vongphachan
<br />14a. INFORMANT -NAME
<br />Villa Boutmahavonp
<br />16a. EMBALMER -SIGNATURE
<br />Brandon S Bachle
<br />16b. LICENSE NO.
<br />1537
<br />16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN
<br />Westlawn Memorial Park Crematory Grand Island
<br />17a.FUNERAL :HOME NAME AND MAIUNG ADDRESS (Street, City or Town, State)
<br />Apfel Funeral'Home1123 W. 2nd, Grand island, Nebraska
<br />CAUSE OF DEATH' (See inatruetioriS and examples)
<br />ta. PART I. Enter the sham of events- .diseaess, in)urtes, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest,
<br />respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br />IMMEDIATE CAUSE:
<br />IMt euTtt<A.usstmnaf a) Sepsis
<br />dice iss of condition reab8ing
<br />In death) - DUE TQ, OR AS A CONSEQUENCE OF:
<br />sequenualy Itat conarttons, if b)MRSA-Osteomyelitis Knee
<br />any, wading to the.:csusa:listed
<br />DUE TO, OR AS A CONSEQUENCE OF:
<br />Entert w Ciffat :TING CAUSE C)
<br />(dlseas 'd wire !bat k iNtf d '
<br />the sweet* resulting in death) DUE TO, OR AS A CONSEQUENCE OF:
<br />LAST d)
<br />18. PART It OT#fER SIGNIFICANT CONDITIONS -Conditions contributing to the:death but nacres g Im the.:
<br />Sever i CalOcie Malritib ition, Psoriasis, Alcoholic Liver Disease
<br />20. IF: FEMALE;..
<br />❑ :Net pre.9ncnt wRMn peat:yei
<br />pregnantattieteofdeath :
<br />0 Not pregnant, but pregnant within 42 days of death
<br />0 Not pregnant, but pregnant 43 days to 1 year before death
<br />Unknown itpregnancwithin the past year
<br />22*. DATEOFINJURY'(MP; Day, Yr.)
<br />22d. INJURY AT WORK?
<br />AYES ;Quo...::;:.:..
<br />21a. MANNER OF DEATH
<br />Natural ❑ Homicide
<br />❑ Accident ❑ Pending InvNtige
<br />0 Suicide ❑ Could not be determined
<br />22b. TIME OF INJURY
<br />22c. PLACE OF I
<br />22e. DESCRIBE HOW INJURY OCCURRED
<br />td'
<br />. 22r LOCATION OF INJURY : STREET & NUMBER, APT.NO.
<br />23a DATE OF DEATH (Mo., Day, Yr.)
<br />October 30, 2021
<br />DATE SIGNED (Mo., Day,
<br />li
<br />'
<br />23b. Yr.)
<br />No.eiriber 2.2021
<br />CITY/TOWN
<br />denying cause given In PART I.
<br />210, (F TRANSPORTATION INJURY
<br />Et Driver/Operator
<br />0 Paesenger
<br />0 Pedestrian
<br />❑ Other (Specify)
<br />14b. RELATIONSHIP TO ttEOEDENT
<br />DauGthter
<br />10c.DATE '(No, Day, Yr) :>
<br />November 6.2021.
<br />1'Jb. t:Cade
<br />6880:1.<
<br />onset to death
<br />Days'. > .
<br />onset to death
<br />19. WAS MEDICALMXAMt t'
<br />OR CORONER GONYACTED"t
<br />DYES ®'No
<br />21c. WAS AN AUTOPSY PI
<br />❑ YES :'
<br />21d. WERE AUJTOPSY'FINDIWGS AYM{LABL
<br />TO COMPLETE CAUSE OF DEATH?
<br />0 YES Q, NO
<br />JURY -At home num,street, factory, office building, construction
<br />STATE
<br />24a. DATE SIGNED (Mo., Day, Yr.)
<br />23c. TIME OF DEATH
<br />11:07 PM
<br />Z9it To the best .of myknowledge, death occurred at the time, date and place
<br />and due to.the:aatess(s) stated. (Signature and Title)
<br />Chad Vieth, MD
<br />24c. PRONOUNCED DEAD (Mo., Day, Yr.)
<br />24b. TIME OF DEATH.
<br />24d.TIME P
<br />tillCOC E.`;
<br />ED, DEAD::.:.
<br />240.On tits bila of examination and%or Investigation, in my oplldoe death occurred at
<br />thatint ;'date and plan and due to the causeis) stated. (Signetts* anti TEte)
<br />25. D1D TOBACCO USE CONTRIBUTE TO THE DEATH?
<br />0 YES .' NO C1 PROBABLY ® UNKNOWN
<br />27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print
<br />Chad Vieth MD, 2116 W Faidley #400, Box 9802, Grand Island, Nebraska 6880;
<br />26a. HAS ORGAN OR TISSUE DONATION.
<br />DYES III NO
<br />TEEN CONSIDERED?
<br />26b. WAS CONSENT (314ANTED7
<br />Not Applicitbe If 26a is NO
<br />N
<br />28e. REGISTRAR'S SIGNATURE
<br />6ci2a,i7 B kot-11 z
<br />28b. DATE FILED BY REGISTRAR
<br />November 5, 2021
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<br />(A„)
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