Death Certificate - McDaniel, Mary_1/26/2012INDIANA STATE DEPARTMENT OF HEALTH ( fj ,j (( tj
CERTIFICATE OF DEATH
1220 AM
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Fwces? 10. If peaN Occ�rteC In A HospUl: f pi. II Deatl� O¢vrtep SmiewTVe O�lt TM1dn A Hpsptal
❑ MosoKZ FaaLb ❑ OeceGenfs Home ❑ NursnB MarcM1Ug{dm Can Fariry
❑ Yes � No ❑ Unkr.rnm � InPa:mt O cmn9e^ry DeDrtrnm� O��a:m� O OeaO m Pmval
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504 NORTH PRINCE STREET
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HIGH SCHOOL GRADUATE OR GED
STURGEON
0 eur:al Q Gemaxn � Da ation � En:mmenent
❑ Re.orW Fran Slate
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�7 �`x 7 No I COLVIN FUNERAL HOME
❑ n�a�nea O�a. em seoaaroa O�o�=ea I
� waw.ea ❑ r+e.a nwnea ❑ u�wa»n
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� �mu� �ae. nnuvumns..nu uamP�esl MOrodmate
ii. Part I. Entu ihe C1��ai� Of Evenls - Diseazes. kyueips, Or CompGCa�,ions - iTai UrecUy Cau5e0 iTe Dea:R Do No� Entp Tartn'vul Even6 Interval: Onsel
Surn ht Cardlac lvre5l Respvatory MeSC Or Ven(rcuWr Fpnllauon V�,hwt Show'vg The EUdogy. Do No� AEGreNate. Enier ONy One Cause On To OeaN
A Line. AEE AECi;inal Lin¢S lf Nece558ry.
HEMODVNANIC COLLAPSE FROlA VOLUME DEPLEf10N AND ANEMIA SECONDMY TO GI
ImmeEiate Cause (Final Disease Or Contli6on R=svlUng In DeaN) A. BLEEDING FROM DUODENAL ULCER 9 DAVS
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Sequen6aAy Us� Candi;bns, If My, �WGing To TTe Cause Lis1eE On 8. BLOOD LOSS ANEMU FROlA BLEEDING DWDENAL ULCER e DAYS
Line A. Enrer TTe Uncer.ying favse (Disease Or Irqury TTat INUateE `� "� °'�
The Evenis Rcw',ling In Dea:h) LaS� �_ qCUTE RENAL FAILVRE FROM ABOVE 8 �AY$
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D. HYPDXIAFROMABOVE 2DAY5
PaM1llEnteONerS'unfian�Ca���tionsCOn�nDUL�woDeaTBU�NOIResulWglnTXeUMeR�ingCauxeGM1inInPM1 39.WasM/wbpsyPMOr�roCi ��� �NO
WO STROKE WITH POOR SWALLOWING AND POOR PO IMAKE. POOR GENEMI CONDITION ANO PATIENTS � yy� �sy Fhy�9 A��de To CortyMele TI�eG�S! OIOeaT?
WISHES TO BE ONLY fAMFORT CARE ❑ �a O No
3t. puioeawoUSeCanTd;t^ioDeaN'! 3�. IlFemale: � �y��p�p�y�;
❑ Yes ❑ PmWEIy � No Q Unknown ❑ Xtln.Pww.�e.e�.� � ny.wun..ac..n � wn.P.Kano.y�.�wa...romao.w � NaW21 Q IionioEe ❑ A¢Nmt ❑ Perqigln�eAgabn
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RAMA
CertifKt ICnad ONy
B YEAGER. VIA
❑ YCf ❑ fJO
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��y> nTTENTION ESTATE: ihe Sodal Sewtlry Y is being repuesteE by Nis state agenq in wder �o pursve responsiG4ry. Disdosure is voluntary and Nue will Ee �ro ce�alq fn retusal.
NR.4-20
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