Death Certificate - Angle JR, Alvis_10/11/2013,-tam®m OFFICIALI:MORECORD cp DEATH.ORIGINAL(,JmQma?INDIANA STATE DEPARTMENT 0 HEALTH
A% 1''' INDIANA STATE DEPARTMENT OF HEALTH 1019449
CERTIFICATE OF DEATH
� � Local No 000155 EDR No 000000308400 State No 012077
1.Decedents Legal Name(Fist Nude.Lath) la. Maiden Name(If female) 2.Sex 3. Time Of Death 4. Dab Of Dear(I.b Dayttear)
ALVIS R ANGLE JR MALE 07:20 PM 02/18/2013
80 Months Days Hours Minos 12/22/1932 PRINCETON, IN
9.Ever b U.S.Armed Faces? 10.H Death Occurred In A Hcaa taI 10a. If Death Occurred Sanewnere Other Than A Hospital
0 Hospice Facility 0 Decedents Home 0 Nursing Horne/Long-term Care Facbty
0 Yes 0 No 0 Unknown 0 lnpatent 0 Emergency Department Outpatent 0 Dead on Artivel 0 Omer(Specify)
11. Feebly Name(If Not Inuit:tort Give Street and Number)
DEACONESS GATEWAY
12.Cry Or Town,State,And Zip Code 13. County Ol Dead 14. Marital Status At Time Of Death
NEWBURGH, IN,47630 WARRICK 0" o Married.But M� ❑Divorced
0 Mimwe0 ID Never mimeo ❑ DivOrc
15. Surviving Spouse's Name , t 5a.(If Wde)Give Maiden Last Name 16. Decedents Usual Ocomaton 17.Kite Of BusulessMOtsvy
SANDRA R ANGLE GRAHAM COAL MINER MINING
16 Residence-Stab 18a.County 1db.City Or Town
INDIANA GIBSON PRINCETON
18c.Steel And Number 18d. AIa.NO. 18e. Zip Code 161.Inside City tubs?
394'EAST 300 SOUTH 47670 ❑Yes 0 No
19.Decedent's Educasm 20. Decedent Of Hispanic Ongth 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fames Name(First.Middle.Last) 23.Mothers Name(Fist Meddle,Last) 23a.Mothers Maiden Last Name
ALVIS R ANGLE SR SADIE ANGLE DILL
24.Informant's Name 24a.RelatatNi To Decedent 241.Mating Address(Street And Number,City,State,Zip Code)
SANDRA ANGLE WIFE 394 EAST 300 SOUTH, PRINCETON, IN 47670
25.Place Of Disposition
25a.Method Of Disposlton 250.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location•City,Totten,And State
0 Burial 0 Cremation 0 Donatan 0 Entombment
0 Removal From State
OOther(Speer)* WALNUT HILL CEMETERY FORT BRANCH, IN
26.Was Coroner Conmded? 27. Name And Complete Address Of Funeral Fealty 27a. Funeral Hone License Numbs
❑Yes 0 N STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
270.Sgnatire Of Indiana Funeral Service Licensee: 27c. License Minter(Of Lksnseez
ROBERT S STODGHILL, BY ELECTRONIC SIGNATURE FD01024378
Cause Of Death (See Instructions And Examples) Approximate
28.Pan I.Enter The Chain Of Fvents -Diseases,Injuries,Or Canp)Catiab-That Direly 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 Line. Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resudong In Death) A. CARDIAC ARREST DUE TO VENTRICULAR FIBRILLATION 48 HOURS
o..e ta...r...-der
Sequentialy List Conditions, II Any,Leading To The Cause Listed On B. ISCHEMIC CARDIOMYOPATHY 2 YEARS
Line A. Enter The Underlying Cause(Disease Or Injury That Initialed
a.yla,...f�reo.'r
The Events Resulting In Death)Last C.
cuthe tot Al•C...eara cab
D.
Pan II.Ens Omer$g WKanl Conditions Crtributino to Death But Not Refuting In The U ndenying Cause Giuin In Pal I 29.Was An Autopsy Performed? 0 Yes 0 No
NONE 130. Were Autopsy Filoikg Avaaabe TO Comptes The Cause Of Death? 0 Yes 0 No
31.Did Tobacco Use Ccnt'ibu.e To Death? 32.If Female: 33. Manner Of Dean:
❑Yes ❑Probably 0 No ❑llnkr.o.vn 0 wnq.n wig.Pa Y.. 0 e,.P.a Mr...ao-e (3 veee ..a m n.w.w4.,.l dry.ao.r, 0 Natural 0 Homicide 0 Accident 0 Pending Investigator
0 e.P..w...4 P,..,..ti oy.n t-.ems.o... 0 uya,rune...wn.a P..Y.. 0 Sulfide 0 Could Not Be Determined
34.Date Of Injury(MonWDayttear) 35.Time Of Injury 36. Place Of Injury(E.G.Decedents Home.Construction Site,Restaurant,Wooded Area) 37.Injury At Work?
0 Yes 0 No
3&Location Of Injury-Sone 1 38a. Cray Or Tom 380. Sweet 8 Number 38c.Apt No. 380.Lip Code
39.Despite How Injury Occurred 40 If Transportaaon iyury,�Se�ft'
Oa-�•s .�.. des., Op..lsP.e.rl
41. Signature,01 Person Cenryig Cause Of Death: 42.Cert et'(ChM.Orly One)
MARLON DAVID JORDAN, BY ELECTRONIC SIGNATURE el Certifying Physician 0 Coroner 0 Hear O15cer
43.Name.Address And Zip Code Of Person CeM1}yi g Cause Ol Dear: 44. license Number 45.Data Ceruled
MARLON DAVID JORDAN ,4007 GATEWAY BOULEVARD, NEWBURGH, IN 47630 01030224A 03/12/2013
46. Additonal Funeral Service Provider. 47. 'Akas:
48. Sgnatore of Local Heath OSCC. 49. For Registrar Only •Data Filed(MOndvDaylyearr
RICKY B YEAGER,VIA ELECTRONIC SIGNATURE MAR 12 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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yj State Fars 53395 ATTENTION ESTATE:The Social Secudry d is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there wit be no penalty for refusal.
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