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per'<, INDIANA STATE DEPARTMENT OF HEALTH
6: - ,. CERTIFICATE OF DEATH
Local No 001907 EDR.No 000000345411 State No 044330
1.Decedents Legal Name(Fast,Middle,Last) 1a. Maiden Name(If female) 2.Sex 3. Tune Of Death 4. Date Of Death(MorcNDaynear)
CAROL SUE JONES DOUGLAS • FEMALE 11:02 AM 09/26/2013
10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Fac&y 0 Decedent's Home 0 Nursing Home/Lung-term Care Faofy
0 Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Department Ouyatent 0 Dead on Amval 0 Other(Speoy)
11. Facility Name (If Not Ins:tron,Give Street and Number) -
DEACONESS HOSPITAL INC
12.CAy Or Town,Sate,And Zip Code 13. County Of Death 14. Marcel Status At Time OI Death
®M.amed 0 Marred,But Separated 0 Divorced
EVANSVILLE, IN, 47747 - VANDERBURGH 0 Widowed 0 Never Marred 0 Unknown
15.Saviving Spouses Name 15a. (It WYe)Give Maiden Last Name 16. Decedent's Usual Ocogauon 17. Kind Of Business/Industry
WARREN E JONES , HOUSEWIFE DOMESTIC
19.Residence-Sate 18a. County lad. City Or Town
INDIANA GIBSON OWENSVILLE
13c. Seeet And Number 184. Apt No. 19e. Zip Code 18f. Inske City Lima?
8320 SOUTH 550 WEST 47665 D Yes 0 No
19. Decedents Education 20. Decedent Of Hispanic Ongn 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(First Mare,Last) . 23.Mothers Name(Fast,Middle,Last) 23a.Mothers Maiden Last Name
ROBERT W DOUGLAS - VIRGINIA DOUGLAS HOUCHINS
24.Informant's Name 24a.Relatknsrp To Decedent 24b.Mafng Address(Street And Number,City.State,Zip Code)
WARREN E JONES HUSBAND 8320 SOUTH 550 WEST, OWENSVILLE, IN 47665
25.Place Of Disposrion
25a Method Of Disposiodn 250.Place Of Disposition(Name Of Cemetery.Crematory.Other Place) 25c.Location-Qty,Tom,Ask State
0 Baal 0 Cremation 0 Donaaon 0 Entombment
D Removal From State
0 Other(Specify): BLYTHE CHAPEL OWENSVILLE, IN
25.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Faoiy 27a. Floral Horne License Number.
❑Yes 0 N HOLDERS FUNERAL HOME OF GIBSON COUNTY, INC., 319 SOUTH MAIN STREET,
OWENSVILLE, IN 47665 FH89000021
27b. Sgnaure Of Indana Funeral Service Licensee: 27c. License Ntimoer(Of Licensee):
RANDALL K DIKE , BY ELECTRONIC SIGNATURE FD01010177
Cause Of Death (See Instructions And Examples) Approximate
28.Pan L Enter The Chain Of Events -Diseases,Injuries.Or Complicatoes-That Directly 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 Lim. Add Addlinal Lines It Necessary_
Immediate Cause(Final Disease Or Condition Resulting In Death) A. ASPIRATION PNEUMONITIS ACUTE
P+K I6 AuA CewG. •or.
Sequentially List Conditions, If Any,Leading To The Cause Listed On B.
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated a.blp4A:uv}am CA)
The Events Resulting In Death)Last C -
oa to la As A Ca sapww orr
D.
Pan IL Enter Oter SigniScant Condibons Contnmtna to Death But Not Resulting In The Underlyig Cause Gisin In Pant 29.Was All Autopsy Performed? Dyes El No
RESPIRATORY FAILURE 30. Were Autopsy Finding Available To Complete The Cause Of Dean? Dyes 0 No
31. Dud Tobacco Use Conmbo.e To Death? 32. If Female: 31 Manner Of Death:
❑Yes ❑Probably®No ❑UnMkavn 0 we P,e-n Yarn Past Year 0 e,e>,n a rut.a Pain 0 un manta eu Prig-Aril vArnAo Darr a Due, 0 Natural 0 Hank/de D Accident 0 Pending Investigation
0 sun ewa•ew eatv,nw.a ten m+w•teen Dina n 01ke,e-, Pn-rim,.n-Ps'rent, 0 Suicide 0 Coud Not Be Determined
34.Date Of Iryury(Mono/Day/Year) 35. Tune Of Injury 36. Place Of Tinian(E.G..Decedents Home,Constance Ste,Restaurant Wooded Area) 37. than At Work?
D yes O No
38.Location Of Injury-Sate 38a. Crty Or Town 38b. Street 8 Number 38c. Apt No. ' 38d. Zsp Code
39. Decrease How 1,H,Occurred 40. II Transporatan Iryuy, 5
Opw.„welt. 0e. . ,Doeet1
41. Sagsatue,Of Person Cenfiag Cause Of Death: 42. Cett:fier(Check Orgy One)
ANDREI MIHAI CROITORU , BY ELECTRONIC SIGNATURE 0 Caddying Physician 0 Coroner 0 HeatOBcer
43.Name,Address And Zip Code Of Person Cetyug Cause Of Death 44. License Number 45. Data Cer•5ed
ANDREI MIHAI CROITORU , 600 MARY ST., EVANSVILLE, IN 47747 01070432A 09/27/2013
46. Additional Funeral Service Provider. 47. •Akas:
48.Sgnature of Local Health Officer 49. For Registrar Only -Data Filed (Monm'DayfYea):
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE SEP 30 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY O�R ORIGINAL)
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I oState Form 53395 ATTENTION ESTATE:The Social Seouiy A is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
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