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' � � STATE OF NEBRASKA
<br />," �EN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEA
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRA
<br />HUMAN SERVICES, VITAL REC�RDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR V
<br />DATE OF ISSUANCE �/.,d(,G
<br />05/16/2011 20��07��� STAIyI
<br />Sy9
<br />LINCOLIV, NEBR.4SKA HUMAN.r��TRV
<br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES =' '•
<br />3�iUPfiA11i-SER,,VICES, I7 CERTIFIES
<br />'���Nt�AtT QF°f�;F�LTH.AND
<br />�ORDS .�, " � �, �
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<br />��''"� ���101541 �
<br />a.�r�� �rws�i � a�r urr�� n ,.. ,. ., � -��
<br />1. DECEDENTS-NAME (Flrat, Middle, Last, Suftbc) 2. SDC 3: DATE''OF DEI�,'If (Mo, Day, Yc)
<br />Alexander Lut Akl Male MayB;-20'f1
<br />4. CiTY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE • Last Birthday b. UNDER 1 YEAR Sc. UNDER 7 DAY 8. DATE OF BIRTH (MO, Day, Yr.)
<br />lY►$•) MOS. DAYS HOURS MINS.
<br />Hilo, Hawaii 81 April 16, 1930
<br />7. SOCW. SECURITY NUMBER 8a. PLACE OF DEATH
<br />575-28-0285 HOSPRAL � InpaUerrt OTHER � Nursing Home1LTC � Hospiea FacilHy
<br />8b. FACILITY-NAME (If �rot IrtaUhrtion, gNe street ami numbe�
<br />� ❑ ERfOtnpaUent � DecederR's Home
<br />� Good Samaritan Society-Grand Island �Ilage ❑ oon ❑ ocner �spec�ry►
<br />� Bc. CITY OR TOWN OF DEATH (indude Zip Code) Sd. COUNTY OF DEATH
<br />c Grand Island 68803 Hall
<br />� 8a. RESIDENCESTATE 8b. COUNTY 8c. CITY OR TOWN
<br />Z Nebraska Hall Grand Island
<br />LL 9d. STREET AND NUMBER 8e. APT. NO. 9L ZIP CODE 8g. INSIDE CPI'Y LIMfI'S
<br />T 4071 Timberline St 68803 � res ❑ No
<br />� 10a. MARITAL STATUS AT TIME OF DEATH � Marrled � Never Nlarried 10b. NAME OF SPOUSE (Flrst, Mlddle, Last, Suftht) M wlfe, glve maldan name
<br />� ❑ nnamea but separeted ❑ urnaowed ❑ DNorced ❑ unwmwn Sue Louise Omohundro
<br />� 11, FATHER'S-NAME (FI►at, Middle, Last, SuHbc) 12, MOTHER'&NAME (Flrst, Mlddle, Malden 3ur�me)
<br />m William Aki Choon Sung To
<br />°' 13. EVER IN US. ARMED FORCES? G(ve dates ot service BYes. 14a. INFORMANT-NAME 14b. RELAT(ONSHIP TO DECEDENT
<br />E
<br />$ (Yes, No, or unk.) Yes 11/17/1953-09/04/1955 Sue Louise Akl Wife
<br />� 15. METHOD OF DISPOSITION 16a. EMBALMERSIGNATURE 76b. LICENSE NO. 18c. DATE (Mo., Day, Yr.)
<br />F ❑ Burial ❑ Dormtlon
<br />Not Embalmed May 9, 2011
<br />� CremaUon Q ErKombment ��. CEN�TERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br />❑ Removal ❑ Other (Sp�lfy)
<br />Central Nebraska Crematlon SeMces Gibbon Nebraska
<br />17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, Sffite) 17b. Zip Code
<br />All Faiths Funerai Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br />CAUSE F DEATH See instructlons and exam les
<br />1& PART L EMertNe chaln of eveMe��diseasea, InJuri�, or compllcadonathat dtrectly cauaed tlre tleffih. DO NOT errter terminal ever� auch as cardlac arrest, : APPROXIMATE INTERVAL
<br />respiratory arrest, or re�rtHwlar flbrlllation without ahowing the eUotogy. DO NOT ABBREVIATE EMer oniy o�re cauae on a Ihre. Add edditlmml Wies B neceesary. :
<br />IMMEDIATE CAUSE: ; or�et W death
<br />uu�owre ca,se c� a) PneumoNa ; Days
<br />disease m conditlon resultlng
<br />��'� DUE TO, OR AS A CONSEQUENCE OF: ! o�et to death
<br />s�n�.�i�s��o,�,n b)Severe O�cygan Dependent Chronic Obstructive Pulmonary Disease E Years
<br />a�ry. leading lo the cauae Ilet�l
<br />on Rne a
<br />DUE TO, OR AS A CONSEQUENCE OF: : a�et to death
<br />Enmr Me tnmERLY1N6 CAUSE �)
<br />(dl� or InJury that Initlated
<br />t1re 8"8"m r�"mng In d�U') DUE TO, OR AS A CONSEQUENCE OF: � orreet to death
<br />� d)
<br />�
<br />18. PART tl. OTHER SIONIFlCANT CONDITIONS-Conditlona conMbuting to the death but rrot r�ulUng fn the urMeriying cause gfven In PART 1. 19. WAS MEDICAL E%AMINER
<br />Hypertension, Diabetes, OR CORONER CONTACTED4
<br />� ❑ YES � NO
<br />W 20. IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJU 21c. WAS AN AUTOPSY PERFORMEDI
<br />LL
<br />� � Not P�9�m�rt wtthin �St Y� � Nffiuwl � Homiclde � DrlvetlOPerstar � YES � NO
<br />v ❑ a�e�c � n� m a�sn � n�a�r � Pandi� Imeatl9atlon � a��ge•
<br />,�` � N � �� � p ���� ��� � SWdde � Coutd not be determirtetl ❑ Ped°atrla° 2'1d. WERE AUTOPSY FlNDINGS AVAILABLE
<br />� Na pregnane, but pre¢nane 4s days to 1 year before deatn � p� � TO COMPLETE CAUSE OF DEATH?
<br />� � Unlmown H pregnant withln Ure past yrear ❑ YES ❑ NO
<br />E 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY Y1e. PLACE OF INJURY-At home, tamy atreet, factory, oftice building, eonatruetion ske, etc. (SpeeHy)
<br />$
<br />.� 22d. INJURY AT WORK1 22e. DESCRIBE HOW INJURY OCCURRED
<br />0
<br />�' ❑ YES ❑ NO
<br />22G LOCATION OF INJURY - STREET 8� NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE
<br />23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br />.� � May 8, 2011 ,� � �
<br />� � 23b. DATE SIGNED jMo., Day, Yr.) 2�. TIN� OF DEATH ��� r 24c. PROIdOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br />� Z Ma 9, 2011 07:30 AM d<�
<br />$�� To the beat of my Imowied8e, tleatli oeeurred at the tlme. date and plaee $��� 24e. On the 6asla W exsminaGon and/or imesd9etlon. in my oPidon deaM oaumed at
<br />�� and due to tlre eeuse(s) sfatetl. (Signafure and TIUe) o�� the tlme. date and Piace a�M due to the aausa(sl atated. (Slgnature ami Titte)
<br />� Jay C. Anderson, MD '' �;
<br />2S. DID TOBACCO USE CONTRIBUTE TO THE DEATH4 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 286. WAS CONSENT GRANTED4
<br />� YES � NO � PROBABLY � UNFdVOWN � YES � NO Not Applieable H 28a Is NO � YES � NO
<br />2. TITL D ADD F CERTIF R(PHY IC , HYSIC ASSIST T, O NE '3 P SIC R COUNTY A ORNEI� ype or Print)
<br />Jay C. Anderson, MD, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br />28a. REGl3TRAR'S SIGNATURE �� 28b. DATE FlLED BY REGISTRAR (Mo, Day, Yr.)
<br />May 10, 2011
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