Death Certificate - Thomas, Myrtle_4/3/2013 (2) p_-_
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` INDIANA STATE DEPARTMENT OF HEALTH 8 6 3 9 8 3
CERTIFICATE OF DEATH
'� .;.,. Local No 001952 EDR No 000000284441. State No 046243
1.Decedents Legal Name(rest Mdde,Last) la.Malden Name cif female) 2.Sex 3.thane Of Dean 4,Dab Of Death(Mo,V•AayHeart
MYRTLE LUCILLE THOMAS CRAIG FEMALE 10:15 AM 10/12/2012
5. Social Security Number ea.Age-Yrs 6b. Under 1 yew ec Under l Moran ed.Under 1 Day 6e.Under 1 Has 7. Date of Seth(MPNNDaytiear) 8.Encino(City and State a Faei i Carty)
80 Mons Days Hots Mntaa 07/10/1932 . BRAZIL;IN
9. Ever in U.S.Aimed Forces? IO.If Dural Occurred In A Hosp'I}2 10a. If Death Occurred Somewhere Other Than A Hosttat
0 Hasp a Facility 0 Decedent's Hare 0_Niesing Hanertag-tenn Care Fusty
0 Yes 0 No 0 Unl,own 0 Ltpaient 0 Erbrgerhcy Deal nmea Outpatient 0 Dead an Arrival 0001er(speoly)
II. Facility Name(If Not Insiwaot Give Sven and Number)
DEACONESS HOSPITAL INC
12.City Or Town.Slate.AM by Code 13.Cant)Of Death 14.Mantel Status Al Taw Of Death
EVANSVILLE, IN,47747 0 Matn.d0 Manned.But Separated 0 Divorced
VANDERBURGH 0 wwowed 0 Never Marred 0 Unknown
15, Sinning Spouse's Name 15a.(v V,L'e)0 m Maiden Last Name 16. Decedents Usual Oatpaion 17.Iced Cf puness/Industry -
HOMEMAKER HOUSE
I9.Residence-State tea. Carry 18b. City Or Toms
INDIANA GIBSON FRANCISCO.
18c. Street And Neither 180.APL No. tea.Zip Cede 167. Inside City Liras]
R.R. 1 BOX 200 47649 ®Yes E)No
19.Decedents Eduraten 20. Decedent Of Hispanic Onan 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(Fist Middle.Last) 23:Mothers Name(First,N.idde.Last) 23a.Mothers Maiden Last Name
WILBUR LEANDER CRAIG REATHA ALICE CRAIG BURCH
24.Inbrmaa's Name 24a.Reatmsnp To Decedea 24b.Mateo Address(Steed AM Number,City.State.Zip Code) -
MIKE THOMAS SON 7 CONSTANCE AVE, METHUEN,MA 01844
25.Place Of Cryposaica
25e.Mel od Of Dupouaen 250.Place Of Oisposbon(Name Of Cemetery,Crematory.Other Place) 25c Location-City.Toms.And State
0 Burial 0 Cremation 0 Dorabon CI Emanaxra
0 Removal From State
O other(spedfy): AUGUSTA.CEMETERY - AUGUSTA, IN
25.Was Coroner Contacted? 22.Name And Complete Address Of Funeral FacGy
27a Funeral Home License Nurllber.
❑ells 8 No LAMB BASHAM MEMORIAL CHAPEL, INC.,226 E.WASHINGTON STREET,OAKLAND CITY,
IN 47660 FH83005312
27b. Synelue Of tenable antal Service Licensee: 27c LicenseN (Ol Licensee):
JERRY LEE BASHAM, BY ELECTRONIC SIGNATURE FD01016589
Cause Of Death (See Instructions And Examples) APPrer nese
28.Pan I.Enter The Chan Of Events -Diseases.Injuries,Or Compecatiorss-That Directly Caused The Dealt Do Not Enter Terminal Events INavat Onset
Suds As Cardiac Arrest Respiratory Arrest,Or Venhioaar Fibrillation Wtout Shoeing The Etiology.Do Not Abbteviate.Enter Only One Cause On To Death
A Lite. Add Addsnal Lines If Necessary. -
Immediate Cause(Final Disease Or Condition Resuting In Death) A RESPIRATORY FAILURE DAYS
- Da b Ice N A Cyr>®a,
Sequentially List Condioms, If Achy,Leadng To The Cause Listed On B. ENCEPHALOPATHY
Line Enter The Underlying("nice(Disease Or Injury That Initiated Wwla An.c.,,.e.,var DAYS
The Events Resid'ng In Death)Last - C. HYPOGLYCEMIA DAYS
p„,,,,,,„w ACwgm%
• D. DIABETES - YEARS
PM IL Enter omerSwelcant Ccndeons°wrote:be to Death 8u Not Rowan;In The UMerlyiig Cause SW In Rani 29. Was An Autopsy Performed]
❑Yes 0 N
GENERALIZED DEBILITY,HYPERTENSION.DEMENTIA - 30.Vita Autopsy Finding AVaietb To CanIXCe The Cause QDeath?
31. old Tobacco Use Calmbeite To Death? 32.II Female:-- 0 Yes 0 Tobacco
•- 31 Meurer Of Death
❑Yes ❑Itleya,:vare.Nes.., 0 PN M?p awns O Wr TAY ea snow* C tun a0.. _ 0 Penang Lwea'Ygst n
❑Probably 0.No 0 Unaxwm 0 Sthddl 0 Homicide Be AxMa Pe
3,, Dated ❑.i•i^wu ueereeoone r.I rands.one 0onwn brain en..e r..• ❑Slwa 0 Cart Na e Demmuled
IOO(Ma tITD47YeaO 35. Tune 01 men 38. Phan a injry(E-G,Decedent's Hone,Construction ate,Restaurant Wooded Area) 37.Islay At Werth
0 Yes 0 No
38. Location Ol friary.State 38a Cry Or Town 38b. Street a Number 38c. Apt No. 384. Zip Code
39.Describe How Irryry Occurred
b. If Transpiebt trery,Uea,Y
Oa.os-+. On-iw❑rye.Doe-w...n
41. Sealaare,Of Penn Cenityey Cause a Deem.
DOUGLAS JAYE HATLER , BY ELECTRONIC SIGNATURE <2. caner(Check Only One)
43. Name,Address And arty'uq P44.Lic 0 er ❑.Heel Ce$
Zip Cade Of Person Cr'ybtp Caine Ceaseq Death: a4. License NUnber 45. Data Cr Sad
DOUGLAS JAYE HATLER ,4498 FIRST AVENUE, EVANSVILLE, IN 47710 01039937A 10212012
46.Aatiwnal Funeral Service Prnlder. 47. 'Mrs:
48.Signature a Local Meaith Grocer.
49. For Registrar Only -Date Flied(month/Day/Year):
RAYMOND W. NICHOLSON,JR.,VIA`ELECTRONIC SIGNATURE OCT 22 2012
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
State Form 533 ELATION ESTATE:The Social Sean 0 is being r
lyy - T Security g eµles;ed by this stele agency in order to pursue responsibility. Dizr Josue is vohagary and there will be no peony for refusal
(7/05)
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