Death Certificate - Ziimmerman, Mary_5/9/2013 (4fe,re� • • INDIANA STATE DEPARTMENT OF HEALTH 8 6 0 4 5 9•0 CERTIFICATE OF DEATH
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t/ ,. Local No 001306 EDR No 000000269534 State No 030746
1.Decedent's Legal Name(First Midas.Last) 1a.Maiden Name Of female) 2 Sex 3. Tree Of Der 4.Data Of Death(AbrCVfbyryea4
MARYAZIMMERMAN COOPER FEMALE 06:25 PM 07/09/2012
10.11 Dead"Coasted In A limpet 10a II Death Occurred Somaxtes,°the Than A Hospital
D Yes ®No 0 Unkno m 0 BpaSerg 0 Emerge/1W Depetaarp 0uyalien 0 Dead m Armed 0 Hospice Fealty ❑Drente Rs Nan. ❑Nursing Ha eBmP em Ca.FmSy
❑Other(SMOfY)
11. Faddy Name(If Not InstSUwt Carve Street and Mmnter)
ST MARY'S MEDICAL CENTER OFEVANSVILLE, INC
12.Cry a Tomt Sea,And Zlp Code 13. Casey Of Der 14.Marital State At Tens a Death
EVANSVILLE,IN,47750 ='•. VANDERBURGH � 0 Wowed p era Meow Divorced
❑Unknown
15. Swhine Spouse's Nun ,•L I, 1 -. - 15a Of VMe)Give Maiden fast Name 16. Decedent's Uslal OWpatal _ 17. Kai Of 9aulesNM,utry
LICENSE PRACTICAL
NURSE MEDICAL
19. Residence-Stan lea. Carey 180. Ctya Tam
INDIANA GIBSON PRINCETON
lac Street And Number
1Bd.Apt NO 184_ 20 Code 181.Ire at/la-.3s?
319 WEST MONROE STREET 47670 O Yes O No
19. Decedents Education 20. Decedent OlHispaic Ongn 21. Decedents Race
ASSOCIATE DEGREE(AA,AS) NOT HISPANIC White
22.Fathers Name(Fest Middle.Lure 23.Meets Marne(Fist Mille,Last) 23a.Mothers Maiden Last Name
JOHN COOPER ALICE COOPER SHEPARD
24.INamarts Name 24t Relationship To Decedent 24b.Mang Address(Street And Ntm1ber,Ciy,Stye,Zip Code)
DAVID ZIMMERMAN GRANDSON 420 WEST GLENDALE STREET,PRINCETON, IN 47670
25.Few e on
25a,Medved Of Disposes., 25e.Raw Of Mama Of Cmery,Crematory.Other
Race) 25c Location-Coy,roan And Sao
®Burial ❑Cremation ❑DawSm❑Emmnhreu
0 Removal From State
0 Oesar(Specify): MAPLE HILL CEMETERY. PRINCETON, IN
26.Was Catow Cavrcad? 27. Name And Complete Address Of Fsnea Faulty Va. Farrel Haw tiaree Ma:en
❑Yes ®"° '
COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
270.Sigranra OI Wane Flea)Ser.te Lb:Mae: i 27c.license Muter(Of Licensee)
JOHN W WELLS,BY ELECTRONIC SIGNATURE IFD01009940
Cause Of Death (See Instructions And Examples) Appruvnye
28.Part L Enter The Chain Of Events -Diseases,Initries,Or Canpace0aa-That Directly Caused The Death.Do Not Enter Terminal Events Irtevat Onset
Such As Carte Arrest Respiratory Arrest Or Ventricular Fisaation Veout Shoving The Etiology.Do Not Abbreviate.Enter Ony One Cause On To Death
A Line. Add Ad dial Lines H Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A SEPSIS 2 DAYS
MY M eec Unwary.Oh
Sequentially List Conditions, If Any,Leading To The Cause Listed On a CCILO-PSOAS FISTULA 30 DAYS
Line A Eger The UMeryig Cause(Disease Or lruy That Initiated
aaslnw.c...emw
The Events Resulting In Death)Last- . C. ACUTE MYOCARDIAL INFARCTION POSTOP
pass la wee&ove,mos
D.
PM 11.Enter Other Spa fi211I Corvette net Catotbg a beam Ott Not ReMSng In The UMMyig Cause Gisin In Part I 29.Was An Autopsy PMamed?
0 Yes 0 No
30. Were Autopsy Findlng Available To Compete TM Carne Of Death?
DIABETES 0 Yes 0 No
31.Did Tobacco Use Comte.To Dayh? 32.If Female: 33. Mamas Death:
❑Yes ❑ProOebly No ❑Unknown
0 Me rn-i ne'a wee. 0 acres N net a de 0 w*woes.ea a.m..otos Cent a ono ®Natal 0 Homicide 0 Accident 0 Penang lmampcm
0 se mee.4unerve lair.r.I we...Duo 0 °""n'' n no-...., 0 Sudde 0 Cold Not Be Determined
34. Data Of Injury(MagvDsyrYeat) 35. Tine Of Injury 36. Firms OI MOW(E.G..Decedents Home,Construction Site.Restaurant Wedded Mn) 37. testify At Vet?
D Yes 0 NO
38. Leann Of Ijuy-State 38a Cay Or Tom I 38e. Street 8 tenter Sac Apt No. Sad Zip Cow
39. DesPim Haw eery Ommed ' 40. If Transportation Irjlry,
Owesooe.a Daaarg•Ell heart,°Cawown
41. Sipnyue,Of Person Certifying Cauca Of Death 42.Certifier(Check Orly One)
STACIE WENK, BY ELECTRONIC SIGNATURE ®CectiMroPtyddan 0 Coroner 0 HutObur
43.Name,Address And Zip Code Of Person Ce ifyeg Cause a DeeN 44. License Mahe 45 Dye Certified
STACIE WENK ,3700 WASHINGTON AVENUE, EVANSVILLE,IN 47750 02002229A 07/12/2012
48.Atrlmaal Amoral Sewice Provider. 47. -Akar
48.Signtra ci Leal Hedth Oaken 49. For Registrar Only -Data Fled(MantdDay/Yee) a
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE JUL 13 2012
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
a&-Q- 0"- 303- 003. 3 '8a -028
2c- 1a-- O 1 -303 - 015a • 583- az8
•
State Fain 533 ATTENTION ESTATE:The Social Seemly I a being requested by this state agency en order to pursue reSponsibddy. Disdosue is vWnary and there veil be no pesmiy for refusal
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