Death Certificate - Gibbs, Margie_5/24/2013 IiWblIKIM llliiIIIFI IIAiIla:RNt1:PII1a117:11;MIThhIF1IH tK11Ji11PII,i:t.t11:21:R.71:11atli'L'1:11 i:11t1J:1i1 9 5 2 3 91
as` INDIANA STATE DEPARTMENT OF HEALTH
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Leading To The Cause Listed On B. ACCIDENTAL FALL
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Line A. Enter The Underlying Cause(Disease Or Injury That Intuted
The Events Resultrg In In Death)Last C
eta to I O.A.a ra..e.ne CO-
Part II.Enter Other Signitcant Cordons Cor nbutirc to Death Eta Not Reshitng In The Undertyeg Cause Orson In Pan I 29.Was An Autopsy Pedomed? D Yes 0 No
COUMADIN PATIENT
30.Were Autopsy Finding Available to Complete The Cause Of Dean? oYes 0 No
31.Did Tobacco Use Cas:Mte To Death? 32. It Female_ 33.Maurer OI Death:
❑Yes ❑Probably 0 No ❑Unknown 0 wr Pnawewe ePr Year 0 t*9wau Tee Of Dorn 0 rue 'err'u 14.7.1,0•4L,0 n ern corn 0 Natural 0 Homcide 0 Acaderc 0 Pew,g Imesrgaton
❑ea...v+n e4 Pales a dr.tee yes'son.doh 0 U-asan∎P,e ..e Vann,ti Pre v.r. 0 Suicide 0 Cold Not Be Detemined
34.Data 01 lniury(Month/Day/Year) 35. Tire Of Injury 38, Place Of Injury(E.G..Decedents Home,Constucbon Ste,Restaurant Wooded Area) 37. In pry At Wort?
04/26/2013 00:10 HOME D Yes 0 No
38.(oration Of Iryuy-State 38a. City Or Town 38t. Street 8 Number 38c.Apt No. 38d. Zip Code
INDIANA PRINCETON 711 SOUTH STOUT STREET 47670
39. Desmoe How injury Occurred 40, If Trahspotatm lryry,Soecry_
porn.eerie 0.4www O' - pae'tsen,l
FALL AT HOME FROM STANDING POSITION
41.Signature,Of Person Certtyig Cause Of Death: 42 Certifier (Check Only One)
ANNIE E. GROVES, BY ELECTRONIC SIGNATURE 0 Caniying Physioan 0 Corona .0 Heat,O-hoer
43.Name,Address And Lp Code Of Person Cerayi g Cause Of Death 44. License Number 45. Data Certified
ANNIE E. GROVES ,201 S. MORTON AVENUE, EVANSVILLE, IN 47713 NONE 05/17/2013
46.Additional Funeral Service Raider 47. 'Aster.
48. Signature of Local Health Officer 49. For Reglstnr Only -Date Filed (Mont/Day/Yew),
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE MAY 20 2013
I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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s. ` .a�- «-o7- 404- COa. 743'Day
.Stale Form 53395 ATTENTION ESTATE:The Soda)Security a is being requested oy this state agency in order to pursue responsibilty. Disclosure is voluntary and there will be no panty for refusal.
t fNRA-20
(7/05)