Death Certificate - Christmas, David_7/15/2013 • \ '1• 1 1 -, I I .1"it •fl l 17".1 .1 'P7- I •.•..1). I • - ' 11' I 1• 17•'I' '' 7' ,1 7'1 firs
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r'Fah INDIANA STATE DEPARTMENT OF HEALTH 101716 9
/ei ,.. CERTIFICATE OF DEATH
\� .i. Local No 000283 EDR No 000000323069 state No 023568
1.Decedent's Legal Name(First Midie.Last) la.Maiden Name(If female) 2.Sea 3. Time Of Death 4. Date Of Death(MOn?slDayfYear)
-
DAVID VANN CHRISTMAS .I
MALE:. 10:45 AM 05/09/2013
0 Hospice Facility p Decedents Home -p Nwsalg Homeitorg-term Care Faciity
p Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Department Oumatient 0 Dead on Areal p Other(Specify) -
I1.Fealty Name(If Not Irsob',ion,Gale Street and Number)
DEACONESS GATEWAY
12.City Or Town.Sate,And Zip Code 13. County Of Death - 14. Mental Stasis M Time Of Death
®Marded p Married.But Separated 0 Oivoeted
NEWBURGH. IN, 47630 WARRICK • O Widowed p Never Maried ❑Unknown
15. Survmng Spouse's Name 15a.(If WLe)Grve Makin last Name 16. Decedents Usual Occupatio n 17.1(Ind Of Business/Industry
SHARON CHRISTMAS GOODMAN MAINTENANCE MANUFACTURING
18.Resider.z-Sate 13a. Cowry 180. City Or Town
INDIANA - GIBSON PRINCETON
113C. Street And Number 113d. Apt.No. :Be.Zip Code 1St.InsdeCity ?
201 EAST INDIANA STREET 47670 ®Yes D No
19. Decedents Eduotan 20.Decedent Of Hispanic Ong., 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED I NOT HISPANIC White
22.Fathers Name(First saddle,last) 23.Mothers Name(First Made.last) 23a.Mothers Maiden Last Naze
DAVID CHRISTMAS MARY ANN CHRISTMAS PATTON
24.Informants Name 24a.Relatonsom To Decedent 240.Maeng Address(Street And NLmcer,City,Sate,Zm Code)
SHARON CHRISTMAS SPOUSE 201 EAST INDIANA STREET, PRINCETON, IN 47670
25.Race Of Disposition
25a.Method Of Disocvton 25o.Place Of Dspossoi(Name Of Cemetery.Crematory.Other Place) 25c.Location•City,Tam,And State
0 Burial 0 Cremation 0 Donation 0 Ensarament
O Removal From State
p Other(Specify): BURRIS CHAPEL CEMETERY LINTON, IN
26.Was Coroner Contacted? 27. Name And Compete Adorns Of Funeral Facity 27a. Funeral Home License Wader:
o Yes 0 No COLVIN FUNERAL HOME INC.425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27b. Signature OI Indiaa Funeral Service Licensee: 27c.License Number(Of Licensee
MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See Instructions And Examples) Approxima te
28.Part I.Enter The Stain Of Events •Diseases.Injuries,Or Complcatiols-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest.Respiratory Arrest,Or Ventnoular FibNlation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. ANOXIC ENCEPHALOPATHY
o..nta...m,....,.v on -_ -
Sequentially Ust Conditions, If Any.Leading To The Cause Listed On B. ACUTE RENAL FAILURE
Line A. Enter The Undedying Cause(Disease Or Injury That Initiated d..lo...d.,..,...04
The Events Resulting In Death)Last C. ACUTE LNER FAILURE
a.w to...d...,...or
D.
Pan II.Enter Other Significant Conpdms Cent/00M to Death But Not Resulting In The LNOMying Cause Given In Part I 29. Was An Au psy P fOtmed? 0 Yes 0 No
GASTROINTESTINAL BLEEDING
30.Were Autopsy Finding Avaaatle To Compete The Cause Of Death? p Yes p No
31. Did Tobacco Use Contribute To Death? 32. If Ferrate: 33. Manner 01 Death:
0 wn.m..WIt.Res n. 0.ywu r..pat.. 0 vev,.e,.t a.nm.e we...7o.nptd.e ®Natuzl O Horndde .p Accident p Pendiglnvesiga5x®Yes ❑Probably p No ❑Unknown
0---w9.F.w..4 en. .,Tee e.s.dm pt.....' we.e.e..,v- 0 Suicide 0 Could Not BeDetermined
34. Data Of Injury(Fbnthrmayfrear) 35. Time Of than 36. Place Of Injury(E.G.,Decedents Home.Construction See.Restaurant.Wooded Area) 37. Injury At Wort?
p yes p No
38. Locason Of Injury.State 38a.City Or Town 390. Street 8 Number 3M. not No. 38d. Zip Code
39. Describe How InNry Occurred 40 II Transpmation Injury, fy.
psea'ce Ci-- « ' po.ets..drs
41. Sgnawre.Of Person Cer-tog Cause Of Den: 42.CeriSer(Cheat Only One)
BASSAM YOUSEF, BY ELECTRONIC SIGNATURE ®Cenaying Physician 0 Coroner 0 Heath Offser
43. Name,Address And sip Code Of Person Certfytng Cause Of Death: 44.License Number 45. Date CertSed
BASSAM YOUSEF , 600 MARY STREET, EVANSVILLE, IN 47747 01042166A 05/17/2013
46.Adotanal Funeral Senile Pt- en- 47.'Akas:
48. Signature of Local Hearth Offerer. 49. For Registrar Only •Date Filed(Mpr3AiDayiYeaY
RICKY B YEAGER,VIA ELECTRONIC SIGNATURE MAY 20 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
o26_ ca leg-aol-c co • 31 a - Da c
Slate Foe 53395 ATTENTION ESTATE:The Social Searnty a is being requested 0y this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penally for refusal.
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