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WHEN THIS COPY CARRFES Tim RAISED SEAL OF THE NEBRASKA HEALTHAND )"ONSERVICES SYSJEM, RCERTIF/ES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL MBQQRD_Oil FILE WITH TWt NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIST SE i1L — yVFlICM IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. _ DATE OF ISSUANCE = - -- r � .STAN EY S. €VDPER , AUG 13 2004 200408447 ASSISTAW -V _.— (aF* R LINCOLN, NEBRASKA HEALTH AT!® M IMAW S9*ft1, ft;"7EM STA7EOFTMASKA- DWARiMDUGFirALIMAMK MMSERVXZS - - VfIAL S'TA'y15i1CS fl 018 81 CER71FICATE OF DEATH - — t. DECEDENT. NAME FIRST MIDDLE LAST 2 SEI S- DATEOFDE'ATH aft aw vw Linda Saycocie Female lFebruary18, 2003 a. CRY AM STATE OF BIRTH RIeaIM USA. RaMeaelWyl SW. AGE- LMUVWb UNIM1YEAR UNDER1DAY B. DATE OF BIRTH *MR Z* Va" Thakha Laos (Yes I 57 Au st 8, 1945 5b. MOS + DAYS X. HOURS MIRS . SOCIAL BECURW NUIlER as PLACE OF DEATH 515 -82- 3782 "tWs AuL' ®""'"' °'"ES'' ❑ ❑ ER OUW&W ❑ Raaldallte aL FACILITY -Moo //,pri1YAb1LyNAWI ^vnL"w St. Francis Medical Center ❑ ODA ❑ O1MfsP'`" Or, CITY TOWN OR LOCATION OF DEATH ad ASIDECRY_ - FAIT <, an r�Q(p�_TY pF -p�Ty Grand Island Nebraska Ya 0 Nb ❑ k RESIDENCE -STALE 9b COUKry CITY. TOWN OR LOCATION 90 STREET ANO NUMBER RncUcVQZP CaON 9e ON" CRY UNITS Nebraska Hall 19C Grand I a Ya No ❑ 10 RACE -N•0. wN1i. BMCa Anenpll Wl/lan 11. ANCESTRY lag NINO. Mwea ft Grntn. eel 12. [id MARRIED El 13 NAME OF SPOUSE a o* pwNoift" NY rellsaeM Asian ISa�MI LaotioII NEVER OIVORCED Sisavath SS code tat USUALOOCUPATION /GsaAWtldlOVIId reUM,Mae tab KINOOFBUSWESSIYDUSTRY t5 EDUCATION ISpK#jW*j tMlgalsll or PAM am # umbed Eb wavy or Secwdwv 10.12) C~ I1 J b +• • Homemaker Domestic 12 It FATHER -NAME FIRST MIDDLE UST 17 MOTHER FIRST MIDDLE MAIDEN SURNAME Chang Ket unknown. 1a WAS DECEASED EVER W US ARMERCEST tae INFORMANT • NAME - ... - --... IWIa w w usl l No p1 yss 9n,e ww and does 41 anew Sisavith Sa cocie 111b. INFORMANT MAILING ADDRESS ISAAE ORR O NO,GTV ORTOWN STATE 21P) .. .. 316 West 5th St. Grand Island Nebraska 68801 EMBMIER • SIGNATURE 6 LICENSE NO ... A yE1!AD.OF DIBPOS,TgN 1 21b DATE 21C . CEMETERY OR CREMATORY NAM .. ' 40 E] 02 -22 -2003 Central Nebraska ... 214 CEMETERY OR CREMATORY LOCATION CITY Ow TOWN STATE 2Pa FUNDIA. WME . NAME A fel- Butler - Geddes F.H. ®`"""°" ❑°aiuno Gibbon, Zb FUNERAL HOME ADDRESS (STREET OR RFD NO CITY OR TOWN. STATE 2N% 1123 West Second Street Grand Island, Nebraska 6880 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR IaI MI. AND kll v4w.1,l h, a ~ SIC a PNtsI DUE TO. OR AS A CONSEOUENCE OF v IIII— l ba.een ~ r+c aa+e• al DUF TO OR AS A CON Mee• nllueen anrs o _ar //S .�NN' w., PART OTIEP SIGNIFICANT CONDITIONS • c"IIIIA 910 e» daAM bta not,Naled PART R IF FEMALE WAS THERE A 2a AUTOPSY 25 WAS CASE REFERRED TO MEDICAL I E` � - f N PREGNANCY IN THE PAST 3 MONTHS•t EXAMINER ER OR CORONER: J (Ages +0 -SID V. No Yes No Yes NO 26s 286 DATE OF INJURY Ab. DAy. Y,J 2Et HOUR OF INJURY - 2W. DESCRIBE HOW INJURY OCCURRED I t�. AccbN ❑ u,loHenl.ned �I � Slande Pe,prg 2BeI aUURY AT WORK 281 PLACE iM:k V At _ , pem weal yebry 26% LOCATION STREET OR R F ° NO CR V OR TOWN STATE blKa SPscrli . _ ❑ '—'a M-wop ^ Ya ❑ NNO cl 274 DATE OP DEATH /RAs Day r J _ 2aa DATE SOMED IAb Day V,) tab TIME OF DEATH —' 27b DATE SIONED ' Ab Dar V, I - 27c TIME OF DEATH - .. tat DEAD V,1 =o3 a PRONOUNCED rf Day. tad. PRONOUNCED DEAD Mar; .z'ty 1757 a M ° M trdTblhabatalnMsroWdWaaawllccw ,adtlMlana . dNranaoMCeanddueblhe 2aaOnfbaladNllawmawama, e �.1� • deill accJ,ad M Cilalal MMNO /7 �� (w1'ryl the bne. daM aM Nate aAd du! b IM CMRe1R MMMI W 1 wd T tswwmn wtd T/e CONSIDERED+ 38b WAS CONSENT GRANTED' ,29 DAD TOBACCp USE CONTRIBUTE TO THE DEATH?. 30a HAS ORGAN OR TISSUE DONATION BEEN YES U. � UNKNOWN YES �ND YES �NO 31 NAME AND ADDRESS OF CERTIFIER iPHYSCM, CORONER S PhySICWN OR COUNTY ATTORNEn :Two a ", Anne K. Morse M.D. 72j North Custex Grand Island Nebraska 68801 .Va qEGI3TW 32b DATE FILED BY REGISTRAR Alb Day n/ FEB 2 4 2003 N