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<br />STATE OF NEBRASKA
<br />
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COpy OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />
<br />:~::':::::'TORY FOR YITAL RECORDS. kMh.... ."'X~
<br />SEP 1 8 2007 :S:~~l*~~~y,
<br />LINCOLN, NEBRASKA 20080814 2 HEAtTtffrRD1itl.flJJH$.~1l$X::
<br />... }EJ ~,~ r; A't""l '2.y;
<br />(.;. ...,,'.. 'i';.~~"": .I..,. \ .' ...1'..' ''If'' :,..
<br />'::,~.. ~;_ ','.,~~,'~::;:':,~,;, ";.'~:,,, "'" ~~"::~'::,,::":i': ~~..:' ,'.;:~~,,:,.::"
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SEFW)~~9SA~,II':($UPJ";' ,'"
<br />CERTIFICATE OF DEATH'\' v.....~...;:,pI;,~,,{....;
<br />I ' DoCoDoNT'S,NAME (~' Middle, Last~'- Suffix) 'if; ~;ii~. ~......, '".w.~DeAT~(MO.. Dey, Yr.)
<br />Chinda KeslavaRl2l Keolavone;'....Man~\,';~..,Ati',t;25. 2007
<br />: 4. CITY AND STATE OR ToRRITORY, OR FOREIGN COUNTRY OF BIRTH Sa. AGo' Last Birthday 5b. UNDER 1 YEAR 5e. UNbERl 'DA,r a.PATo iisiflTH (Mo., Day, Yr.)
<br />...... (Yrs.) MOS. DAYS HOURS MINS.
<br />-Iii
<br />--
<br />
<br />
<br />Pak Sun. Laos
<br />
<br />35
<br />
<br />June 29
<br />
<br />1972
<br />
<br />7. SOCIAL SECURITY NUMBER
<br />
<br />,--:; __5.86~28-6714
<br />a-Sb. FACILITY-NAME (If not institution, give .tree' and number)
<br />'---
<br />
<br />Ba. PLACE OF DoATH
<br />1::t.Q.S.ITIAl.: XI Inpatient QlliEB: CJ Nursing Home/LTC CJ Hospice Facility
<br />
<br />CI ER/Outpatient CI Decedent's Home
<br />
<br />-
<br />~
<br />
<br />
<br />Br anLGH Medical Center West
<br />
<br />C1C01.
<br />
<br />CI Other (Specify)
<br />
<br />9.. RESIDENCE.STATE
<br />Nebraska
<br />9d. STREET AND NUMBER
<br />1108 West 8th
<br />
<br />!lb. COUNTY
<br />Hall
<br />
<br />
<br />Bd. COUNTY OF DEATH
<br />Lancaster
<br />
<br />Li nco 1 n
<br />
<br />68502
<br />
<br />--=~
<br />~
<br />--
<br />
<br />9l.ZIP CODE
<br />68801
<br />
<br />9g. INSIDo CITY LIMITS
<br />~ YES CI NO
<br />
<br />10.. MARITAL STATUS ATTIME OF DEATH
<br />
<br />Merrled CI Neve' Merrled
<br />
<br />lOb. NAME OF SPOUSE (First, Middle, Le.t, Sufllx) If wife, give m.lden name.
<br />
<br />CI Married, but separeted CJ Widowed CI Divorced CI Unknown
<br />
<br />--
<br />--=oil
<br />~
<br />ii
<br />
<br />11. FATHER'S.NAME (Flr.I,
<br />Tiou
<br />
<br />Middle,
<br />
<br />Kesavanh Keopanya
<br />~ Sufllx) 12. MOTHER'S.NAME (Flr.t,
<br />.Ke avone Louane
<br />~--aVaRe
<br />
<br />Middle,
<br />
<br />Malden Surname)
<br />
<br />Unknown
<br />14b. RELATIONSHIP TO DECoDoNT
<br />Wife
<br />
<br />13. EVoR IN U.S. ARMED FORCeS? Give date. ot service it yes. 14..INFORMANT.NAME
<br />
<br />(Yes. no, Or unk_)
<br />
<br />No
<br />
<br />
<br />aV
<br />16b. LICENSE NO.
<br />l/('"'L
<br />
<br />15. METHOD OF DISPOSITION
<br />
<br />deCremation CJ Entombment
<br />
<br />CITY I TOWN
<br />
<br />15c. DATE (Mo., Day, Yr.)
<br />Se tember 1 2007
<br />STATE
<br />
<br />~
<br />
<br />CJ Burlel
<br />
<br />o Donation
<br />
<br />-i
<br />....:::=.!
<br />:= CJ Removal CI Other (Specity)
<br />~-~ Westlawn Memorial Park Cremator
<br />~ -1-7a~'FUN.ERAL HOME NAME AND MAILING ADDRESS (Street. City arTown, Slate)
<br />= Apfel Funeral HOll]e, 1123 West Second.
<br />
<br />18. PART I. Enter the chain of 8Vsntsndiseas9s, inJuries, or compllcatlons..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 />
<br />
<br />Grand
<br />
<br />Nebraska
<br />
<br />II
<br />~
<br />~
<br />I
<br />II
<br />.
<br />I~-
<br />..
<br />
<br />APPROXIMATo INTERVAL
<br />
<br />IMMEDIATE CAUSE:
<br />
<br />I onsello death
<br />I
<br />I .
<br />
<br />
<br />.'lU(.,
<br />
<br />IMMEDIATE CAUSE (Flnel
<br />d__ or condition ",""I~ng
<br />In_)
<br />
<br />(al -1Y /.\\,), M~(,., 'oYJ){\ "iI'
<br />DUE TO, OR AS A CONSoQUENCE OF: t'J\ \J '"
<br />
<br />(b) Su..\otiUYlJ..... \i\tM t>........nu~
<br />DUE TO, OR AS A CONSEQUENCo OF: tf\V A. (IV
<br />
<br />onset to death
<br />
<br />Sequentlelly 11.1 condition., "
<br />.ny,leedlnglothe""u..llltad
<br />on IIn...
<br />Entertha UNDERLYING CAUSE
<br />(dl..... or Injury Ihallnill_
<br />tho ...nt. ","uRing In doath)
<br />LAsr
<br />
<br />onset to deeth
<br />
<br />(e) ~tA..t.K- II f\ f..Ih..j 0.....,
<br />DUUO, OR AS A CONSEQUENCE OF: tJ\ Ac;.c.;" t.. V ,.....4..- \ O~
<br />
<br />(d)
<br />
<br />onset to deeth
<br />
<br />lB. PART Ii. OTHER SIGNIFICANT CONDITiONS.Condition. contributing to th. deeth but not resulting in the underlying ceuse given In PART I.
<br />
<br />19. WAS MEDICAL EXAMINER
<br />
<br />OR CORONER CONTACTED?
<br />
<br />CI YES <<NO
<br />
<br />.
<br />.~
<br />S 20. IF FEMALE: 21 a. MANNER OF DEATH 21 b. IF TRANSPORTATION INJURY 21 c. WAS AN AUTOPSY PERFORMED?
<br />~ CI Not pregnant within pest yesr CI Netural CI Homicide ~DriverIOper.tor
<br />
<br />! CI Pregnant el time 01 death ~ccldentCl Pending Inve.tigetion CI Pessenger
<br />
<br />.~ CI Not pregnant, but pregnant within 42 deys of deeth CI Suicide CJ Could not be determined CI Pade.trien 21d. WoRE AUTOPSY FINDINGS AVAILABLE TO
<br />1:- CI Not pregnant. but pregnent 43 dey' 10 1 year before deeth CI Other (Specity) COMPLETE CAUSE OF DOATH?
<br />
<br />Cl Unknown If pre~1 wi)hl,n the,past,y..r ",Q. \'&S Q NO-
<br />22.: !lATE OF INJURY (Mo., Dsy, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY.At home, farm, .treet, fectory, ottlc. bulldtng, construction site, ste. (Specify)
<br />~ ~. -z,C;. C')- O~,b m
<br />=- 22d.INJURY AT WORK? 22e. DoSCRIBE HOW INJURY OCCURRED
<br />
<br />CI YES
<br />
<br />~O
<br />
<br />
<br />G,V'1Lt"vL 1 S I ~
<br />
<br />
<br />CI YES lilCNo
<br />
<br />MoW Vt..NUv ~u..itlu:t
<br />
<br />22f. LOCATION OF INJURY. STRooT & NUMBER, APT. NO. CfTYlfOWN
<br />\-\ \N ~ '3 '0 Y\ UU'" C? V" tl.r(L l S I CJI\IL..
<br />23a. DATE OF DEATH (Mo" Day, Yr.)
<br />
<br />ST.<m='
<br />JJi:.
<br />
<br />ZIP CODE
<br />
<br />iilE~
<br />
<br />tt~
<br />H
<br />,U
<br />0(
<br />
<br />24a. DATE SIGNED (Mo., Dey, Yr.)
<br />
<br />24b. TIMo OF DEATH
<br />I 'Z.S
<br />
<br />m
<br />
<br />m
<br />
<br />E~!i!
<br />!Ila:
<br />Jf~::;
<br />r~~~
<br />.8~::l
<br />,28~
<br />
<br />24e. PRONOUNCED DoAD (Mo" Dey, Yr.) 24d. TIME PRONOUNCED DoAD
<br />m
<br />
<br />
<br />2007
<br />
<br />24e, On the basIs of examination and/or investigation, in my opinion death occurred at
<br />the time, date end place and due 10 the cause(s) stated. (Signeture and Title) "
<br />
<br />26a. HAS ORGAN OR TISSUE DONATION BE oN CONSIDERED?
<br />
<br />26b. WAS CONSENT GRANToD?
<br />
<br />CI Yo$ CJ NO CI PROBABLY. UNKNOWN r:/.YES ,_!J NO .....Nol Appliceble if 26a is NO CJ YES f'!i. NO
<br />27. NAME, TiTLE AND ADDRESS OF CERTIFloR (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type or Print)
<br />tN. G . S-:rC; So. L\V\ \..0 WI,.u: <.or;l~"
<br />2Bb. DATE FILED AUGIS2RAi (MZ'OOf")
<br />
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