Death Certificate - Townsend, Thomas A_3/1/2012INDIANA STATE DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
Local No UUUU/S EDR No UUUUUUL45415 State No
n
763533
10.1t DeaN O[tvrteE In R Hospi'al: 1pa. It Dea�,h Oc�rteE SaneMice ONer TTan A ibspibl
❑ YPS � No ❑ Un�nOVm � InpaOent � Emeegenry peoN�mt O�tpa]ent 0 U aE on Artival � Hospce FaaLry ❑ OtteOaifs Homa ❑ Nursing HomelLdq-tum Gare Fa 3ry
❑ ONer�Speury)
554 WEST POPLAR AVENUE
HISPANIC
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❑ aemo�al Fran su:e
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RUTH
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❑ VJrtlw.e0 ❑ New Mu�leC ❑ Unkmvm
m , i�. �co,arneuan�amy
POTTER
❑ res ❑ No ALEXANDER FUNER4l HOME, WEST CHAPEL, 2100 W. ILLINOIS STREET, EVANSVILLE,
IN 47712 FH199C
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EFFREY W.ALVEY,BY ELECTRONIC SIGNATURE FD29600045
Cause 0f Ueath (Sea InsWCtio� Antl Eyamples)
i9. Pert I. Enter The Gein OI Evenis - Diseases, Injunes, Or Compliralims � TTa� Diretlly CauseE Tlie DeaLh. Do Not En�b Tumi�l Even�s
Surl� As CaMiac Artes� Resqratory Arrest, Or VmViwlar Fpnlla4on W Noul $howing The EUdogy. Do Not ApbreNate. Entb ONy One Causa On
A Line. Ad0 A40i;inal Lines Ii Necessary.
Imnepiate Gause (Final Disease Or Gon�iOOn Resultlng In Oea4�) A. CMD�O RESPiRATORY FAtWftE
m� n..ew�..
SepumUa9y List ConCltimt, H My, Lraaing To The Cause Lis:^a On B. PIEVRA� EFFUSION
lineA. EntuTlieUMe�yingCaese��iseaseOrin'ryryTnatlni4atetl bjP°��°�'�"
The EveniS ResNting In Dea:h) Last �. PNEUMONW
bIP���Cew�e�
D. PAFAPLEGIA
❑ Ye5 ❑ PmGaNy � No Q UnW�wi�
Z.
(7/05)
� Yas ❑ No
Approumate
mtenaC onse�
To OeaN
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Ves No
. 30. Were A:iSpry FmCcp NvaWde To Cnrtqle3 Tl�e Cause Of Des.'�?
❑Yes ❑No
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IN
CG(VfiM (CIIMt OlYy
Nis sta:a agenry In order to Wrsue resporvsidL.y. Disdos�re is vduntary antl Ihere vNl �e ro
❑ Yes ❑ No
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