Death Certificate - Odom, Kathryn_5/10/2013 • •.i1 ' 1 1 t- 11 - 1 1 1 1
r;""F'` INDIANA CERTIFICATE ROF DEATH HEALTH 1 020968
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'''CIW Local No 000220 EDR No 000000318777 State No 018337
1.Decedent's legal Name(First Riddle,Last) la. Malden Name(ll female) 2.See 3.Time Of Death 4. Data Of Death(MonNDay/Year)
KATHRYN MARIE ODOM FEUSS FEMALE. 04:00 AM 04/13/2013
❑Raspier FaaTry 0 Decedent's Home 0 Nursing Hontlo g-tents Care Facility
0 Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Deoatnent Outpatient 0 Dead on Arrival 0 Other(espedy)
11. Facility Name(II Not Inst.tudor%Give Street and Number)
DEACONESS GATEWAY
12.City Or Tom,State,And Zip Cade ' 13.County Of Dean 14. Mandl Sans At Time Of Death
0 Married 0 Macned,SM Separated ❑Divorced.
NEWBURGH, IN,47630 WARRICK 0 widowed 0 Never Married 0 Unknown
15.Surviving Spouse's Name 15a.(II WJe)6ive Maiden Last Name 16.Decedent's Usual Ocwwton 17.Kiss Of BussneWnarsty
MYLES AUSTIN ODOM TEACHER EDUCATION
it. Residence-State tea. County t80. City Or Town
ILLINOIS WABASH MOUNT CARMEL
tec.Street And Number 18d. Apt No. ' 18e.Zip Cade set. InsideCty Limits?
703 PLUM STREET 62863 0 Yes 0 No
19.Decedents Education 1 20. Decedent Of Itsoante Orgin 21. Decedents Race
BACHELOR'S DEGREE(BA,AB, BS) NOT HISPANIC White
22.Father's Name(First Middle,Last) 23.Mothers Name(First Middle,Last) 23a.Mother's Maiden Last Name
EDWARD H FEUSS DOROTHY A FEUSS ALSPAUGH
24.Irpmanrs Name . 24a.Relationsyip To Decedent 245.Maang Address(Street And Number,City.State,Zip Code)
AUSTIN ODOM - 4. • HUSBAND 703 PLUM STREET, MOUNT CARMEL, IL 62863
25.Place Of Dispassion
25a.Method Of Disposition 250.Place Of Llscosioon(Name Of Cemetery.Crema:py,Other Place) 25c.Location-City.To-cs,And State
0 BMral 0 Cremation 0 Donao n 0 Entombment
0 Removal From State
O Other(Sperry) EVANSVILLE CREMATORY EVANSVILLE, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Farlty 27a.Funeral Home license Weasel':
❑Yes 0 No PIERRE FUNERAL HOME INC.,2601 W.FRANKLIN STREET, EVANSVILLE, IN 47712 FH83001897
27b.Signature Of Indiana Funeral Service licensee: 27c.License Number(Of Licensee)
JAMES A. PIERRE, BY ELECTRONIC SIGNATURE FD29400078
Cause Of Death (See Instructions And Examples) Appmsimate
28.Pan I.Enter The Chain Of Events -Diseases,Injuries.Or Canp8cations-That Overly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest Or ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Lire. Add Additinal lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. METASTATIC BREAST ADENOCARCINOMA
W.bra..a Ce•.w.a•oft
Sequentially List Conditions, If Any.Leading To The Cause Listed On B. ct,.nna 4.,c.,..ince
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C
pin ntw 5.A Cowes“Oh
O.
Part II.Enter Other$bnticant Ccndidons ConTbetno to Deem But Not Resutag In The Underlying Cause EMI In Pan I 29. was M Autopsy Performed? Q Yes 0 No
30. Were Autopsy Finding AYalade To Compete The Cause Of Death?
0 Yes 0 No
31. Did Tobacco Use Contribute To Dear? 32. If Female: 33. Manner Of Death:
❑Yes ❑Prob3py 0No 0llllkMxfl 0nn,».".w nen error... O R.ptw■An im.c.a.", 0 M1dRgt mt.MU Pregnant we Cs Due.Of 0..T 0 Natural 0 HpNCide ❑Accident ❑Pending lmesgabon
0 w Pt.:"....a".••• u Dan Tel-e.e.o..w 0 aa,...se•.w.awe.•n.e.e Y., 0 Suicide O Could Not Be Determined
34.Date Of Injury(MOnesDaylYear) 35. Time Of Injury 36. Face Of Injury(E.G..Decedents Home,Construction Site,Restaurant.Wooded Area) 37.Injury At Work?
0 yes 0 No
38.Location Of Injury-State 38a.City Or Town 380. Street&Number 38c. Apt Hb. 38d.Zm Code
39. Despise How Injury Occurred 40. If Transportation Injury.S fy.
Qan.p..e an/sm., LJ++.^ Qpr..13.KI
41. Signature Of Person Cerufyvng Cause Of Den: 42. Certifier(Check Only One)
BASSAM YOUSEF, BY ELECTRONIC SIGNATURE 0 Certying Physician 0 Coroner 0 Hen Of cer
43.Name.Address And Zip Code Of Pesos CertfyIng Cause Of Death: 44.License Number 45. Date CeM1:sd
BASSAM YOUSEF ,600 MARY STREET, EVANSVILLE, IN 47747 01042166A 04/16/2013
as. Addtmal Funeral Service Provider. ' 47. 'Aka
SHORT CUNNINGHAM FUNERAL HOME MT CARMEL IL 62863
48. Sgnayre of Local Hex..Officer: 49. For Registrar Only -Date Feed(McnWDayiYear)
RICKY B YEAGER,VIA ELECTRONIC SIGNATURE APR 16 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
,I ':
to State Form 53395 ATTENTION ESTATE:The Social Security a is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary end there wa be no penalty for ref Lae'.
NRA-20
(7/05)
>\jatlijuin) W) 0410922)
a lo-is -07- 003 - 0o / 3 - Oa S-
FILED
MAY 2013
GIBSON COUNTY AUDITOR