Death Certificate - Ballard, William T_10/15/2013 THIS'IS. ... .. ICIAL ' OERECORD OF DEATH.ORIGINALaCOPY ONTFILE AT.INDIANA STATE DEPARTMENT OF HEALTH; 1090741
i m INDIANA STATE DEPARTMENT OF HEALTH
,i 4 CERTIFICATE OF DEATH
Local No 001881 EDR No 000000343935 State No 043816
1 Decedent's Legal Name(Fist Middle,Last) 1a. Maiden Name(If femur) 2.Sea 3. Time Of Death 4. Date Of Dear(MortvOayfYear)
WILLIAM T BALLARD MALE . 12:14 PM 09/17/2013
85 Maw Days Han Minutes 09/04/1928 ' GIBSON COUNTY,IN
9. Ever in U.S.Ahmed Forces? 10.If Death 0aarred In A Hosp at 10a. If Death Occurred SameMCre Other Thin A Hospbl
0 0 Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival 0 Hospia Fstry ❑Decedents Hams ❑Nursing HorndM1alptem Care Fadfry
❑Ww(5pstiy)
11.Fa try Name(If Not I stanm,Give Street and Number)
DEACONESS HOSPITAL INC
12.City O Town Slab.And Zip Code 13. Canty Of Dean 14. Mandl Stall At Time Of Deah
EVANSVILLE, IN,47747 VANDERBURGH 0"b°"d Married. M�0 Una
M. Suviu4p Spouse's Name 15a. (If W2e)Give Maiden Last Name 18. Deadens Usual OaWagn 17. lend Ca Busnessl dussy
8. Residence.State ,Be STOCKYARD AGRICULTURE
1
County lea. City Or Town
INDIANA GIBSON HAUBSTADT
18c Street And Number lad. Apt No. 18e. up Code 181. Inside City Limits?
4783 EAST 1150 SOUTH 47639 0 Yes 0 No
13.Decedents Eau:awn 20. Decedent Of Hispanic Cow 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(First Middle,Last) 23.Mothers Name(First.Middle,Last). 23a.Mother's Maiden Last Name
SILAS BALLARD BERTHA AUGUSTA BALLARD THENE
24.Informants Name 24e.Relatautnp To Decedent 24b.Manny Address(Sweet And Mercer,City,Stns,Zip Code)
PATRICIA LOCKYEAR DAUGHTER 4743 EAST 1150 SOUTH, HAUBSTADT, IN 47639
25.Place Of Disposition
25a.Mean 01 Disposed, 250.Place Of Dispcaieon(Name Of Cemetery,Crematory,Other Place) 25c.Location-Cry,Town,And State
0 Basal 0 Cremation 0 Donation 0 Erdanbmem
D Removal From State
OOawr(Spsdry): NORTHVIEW CEMETERY ELBERFELD, IN
26.Was Coroner Contacted? 27. Name Aro Complete Address Of Fine Fairy 27a. Rowel Haute License Numder
®Yes ❑No STODGHILL FUNERAL HOME INC,500 E PARK ST HWY 168, FORT BRANCH, IN 47648 . FH10900013
270. Signature Of Indiana Forheral Service Licensee: 27c. License Number(Of Licensee):
ROBERT S STODGHILL, BY ELECTRONIC SIGNATURE ,FD01024378
Cause Of Death (See Instructions And Examples) ApproxEna:e
28.Part I.Enter The Crean OI Evans -Dicwe.es,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Irtervat Onset
Such As Cardiac Arrest Respiratory Arrest Or Ventricular FWination Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Live. Add Addtifal Lutes If Necessary.
Immediate Cause(Final Disease Or Cordition Restttiq In Death) A RESPIRATORY FAILURE DAYS
w.eta...cases*o
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. MULTIPLE BILATERAL RIB FRACTURES
Line A. Enter The Underlying Cause(Disease Or Iquy That Initiated beep's..fdeee-e dm
The Events Resulting In Death)Last C. BLUNT FORCE TRAUMA TO CHEST
tow b,h Ma C eae Ca
D. FALL
Pan IL Enter Oewrsgrvtcaut Cadmms Carman rg b Dean But Na Resotrg In The Underyi g Cause Groin In Pen I 29.Was M Autopsy Performed?
0 Yes El No
COUMADIN PATIENT 30.Were Autopsy Finding AVa9aN orrpts ll us
a To Ci The Cane Of Death? p Yea 0 No
31.Did Tobacco Use Coalbute To Death? 32. If Female. 33. Maurer Of Death:
❑Yea ❑Probably®No ❑Unknown 0 w-.a...vet Pr vat. 0 Nona rut•a a.n 0 ea sewn an news Ye.,a was was 0 Natural 0 Homicide 0 Accident 0 Penang Investigation
0 wP-o-..id P•nt C vent,',added.wan 0 tea•••te.p-4We..Th.Pad vim. 0 Suicide 0 Cal,Not Be DebmOed
34.pats Of hairy(MOCMDayfl eat) 35.Time OI Injury 38. Place Of I4My(E.G.,Decedents Home,Ccnst ccon Site,Restasant Wooded Area) 37. Injtiy At Wink?
09/12/2013 07:20 AM HOME 0 Yes ®No
38. Loudon Of!sexy-Stab 38a. City Or Town 38b. Street&NUnber 38c. Apt No 30d. Zip Code
-
INDIANA HAUBSTADT 4783 EAST 1150 ROAD SOUTH 47639
39.Desoto How Injury Oconee O If Transp-MDr'-0''`n p- 1
If Ta..e L.I
FELL DOWN THE STEPS AT HOME
41. Sgneture,Of Person Cerdyig Cane Of Death: 42.Certifier(Caeca Only One)
ANNIE E. GROVES, BY ELECTRONIC SIGNATURE 0 C.rttying Physician ®Coroner 0 Heath Mar
43. Name,Address And Lip Code Of Person Cerdyi g Case Of Death: 44. License Hunter 45. Drs Crease!
ANNIE E.GROVES ,201 S. MORTON AVENUE, EVANSVILLE, IN 47713 NONE 09/25/2013
46.Anditmal Funeral Service Pro-iider. 47. 'Akan:
48.Sipfatue of Local Health O15cen 49. For Registrar Only -Date Filed(MontvDay/Year):
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE SEP 25 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
S_ ..
a6-a3 -1 ) - 3oo -000. o43-oa4
State Form 53395 ATTENTION ESTATE:The Social Seuaiy a is being requested by this state agency in order to pursue responsibdiry. Disclosure is voluntary Lary and there vein be no penalty for refusal
tYS., IVRA-20
L � (T/C6) I EEG ALTEREDmERASED0NOTVALID CERTIFIED BY'HEALTHiDEPARTMENT