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200910087 ~ nn { ~ ty :~ ~ U.S. Department of State 2 V ~ ~ ~ / ~ 2 ''' Report of Death of an American Citizen Abroad ~:,; U.S. Consulate General Ho Chi Minh City, 2/18/2009 _.. - (Post & date of issue) SSA No. 506-31-7265 Name in full Chanh Trung Ngo Age 69 Date and Place of Birth 31-Dec-1939 Vietnam C- Evidence of U.S. Citizenship Regular Passport #075383853 Issued On August 12, 1999 K L ~ " f ~ ~ ~ Address in U.S.A. 1511 West Fourth, Grand Island, Nebraska, 68801 United States Of America ~ Permanent or Temporary Address Abroad D4 Yet Kieu, My Binh Ward, Long Xuyen City, An Giang Province, Vietnam Date of death Jan 22 14 2009 (Month) (Day) (Hour) (Minute) (Year) Place of death 04 Yet Kieu, My Binh Ward, Long Xuyen City, An Giang Province Vietnam (Number and street) or (Hospital nr hotel) (City) (Country) ge According To Death Certificate No. 02, Book 1, Issued On 04 February 2009 Cause of death Old A _ _ _ _ _ _ _ _ _ __ _ _ (Including authority for statement - if physician, include full name and official title, if any) _ by the Service Of Justice in An Giang Province, Vietnam Disposition of the remains Prepared/Local ~ ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ sv a Local law governing disinterment of remains provides that Not Applicable `9' ~ Disposition of the effects _ _ _ _ _ _ In care of the family - - - - - - - - - - - - - - - - Person or official responsible for custody of effects and accounting therefore Traveling/residing abroad with relatives or friends as follows: NAMr ADDRESS Hanh My Trung Ngo 04 Yet Kieu, My Binh Ward, Long Xuyen City, An Giang Province, VTNM Informed by telegram or telephone ~ ,~ NAME ADDRESS DATE NOTIFIED i~.: C~C ~ Z - - - - - - - - - ~ -- -..... _ .... ..... .. ........ ........ _ .-. .... -- - _- .,.~ _... --- __ - _~_ ._..._....._ _.. -- -_ ... , _._- _. _.- ..... -.-_ ~ C7 m m Copy of this report sent to: NAM7J ADDRESS DATE SENT My Thi Nguyen 1511 West Fourth, Grand Island, NE USA 68801 2/18/2009 ------py ---~-- ~--- .--__ .-~ .......__ _-...-- ... - ~ Notification or co sent to Federal A enctes: SSA VA C,SC Other _ • --- - _ -. (State Agency) d N W N The original copy ref this document and information concerning the effects are being placed in the permanent files of the -n Department o~ State, Washington, D,C. 20520 0 ~ Remarks'.'' , .;+,., ~ ~ ~~ ~:~ ,~, ~ eon reverse if necessary.) tv s ~S>~AL~ : •r. __. ........_...m .,-. (Sign r all copies) ,«~. ' '~ '" ~'~~ Martin Oppus of the United States of America. r ;^,1 ~ s-• ; Consul DS-2060 ~ For Additional Certified Copies, see http://travelstate.gov/passport/consular_records.hpnl. Formerly OF-180 12-2003