Death Certificate - Smith, Virginia Rose_10/18/2013 gillill luaate►►. snnvo :uanana:►t:lam ignitz itimil i C5F HEA� 11 :t�:iqu 1092918
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.i- CERTIFICATE OF DEATH
S % Local No 000166 EDR No 000000346181 State No 046767
1.Decedents Legal Name(First.Motile,Last) la. Maiden Name(If female) 2.Sex 3:Time Of Death 4. Date Of Deal:(MOntNDayfYear)
VIRGINIA ROSE SMITH __ FEMALE 1 01:45 AM 09/28/2013
5.
COUNTY, IN
a Ever in U.S.Armed Forces? 10.If Death Occurred In A Hcsdal: 10a. If Death Occurred Somewhere Omer Than A Hosgal
0 Horpi-n Fealty ❑Decedent's Hone ®i rsup Ha.ek ong-teem Care Fealty
0 Yes 0 No 0 Unknown O Inpatient 0 Emergency Draronent Outpatient 0 Dead on Anwar 0 Omer(Speoty)
11. Facility Name(If No Insttlton.Ose Street date Number)
TRANSCENDENT HEALTHCARE OF OWENSVILLE, LLC
12.Cory Or Town,State,AndZ,p Woe 13.Cathy Of Dean 14. Manta Stang Al Te:x Of Dear
0 Marred 0 Manned.But Separated 0 Divorced
OWENSVILLE. IN.47665 GIBSON 0 WSdwred 0 Never Manned ❑unknown
15.Summing Spouse's Name 15a (If Wife)Give Maiden Last Name 16. Decedents Usual Occupy on 17. Kid Of Businesstndusoy
WILLIAM EDWARD SMITH SR HOMEMAKER I OWN HOME
18.Residence-Sate t8a-County 180. City Or Town
INDIANA GIBSON FORT BRANCH
18c.Street And Number tad. Apt No. toe. Zip Code tat.garde City Limas?
700 CENTER STREET I 47648 0 Yes 0 No
19.Decedent's Educabm 20. Decedent Of Mariam Ong= 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Father's Name(First Middle,Last) 23.Mother's Name(First.Midge.Last) 23a.Mother's Maiden Last Name
SILAS STRAIN BEATRICE STRAIN UNKNOWN
24.Informant's Name 24a Relatonsnip To Decedent tab.Mai sg Address(Street And Number,City,State,Zip Cade)
WILLIAM EDWARD SMITH HUSBAND 700 CENTER STREET, FORT BRANCH, IN 47648
25.Place Of Disposition I
25a.Method Of Doman n 250.Place Of Dlsposaon(Name Of Cemetery.Cremaory.Other Place) 25c.locator)-City.Town,Arid State
0 Baal 0 Cremation 0 Donation 0 Entombment
0 Removal From State
OOthe(Specify): WALNUT HILL CEMETERY FORT BRANCH, IN
26.Was Coroner Contacted? 27. Name And Cantles Address Of Funeral Facility 27a. Funeral Hone License Number
❑Yes 0 No DOYLE FUNERAL HOME, 520 S MAIN ST, PRINCETON, IN 47670 FH10400010
27b.Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee)
BARRETT W.DOYLE, BY ELECTRONIC SIGNATURE FD29500009
Cause Of Death (See Instructions And Examples) Approximate
28.Par,I.Enter The Chain Of Event% -Diseases.Injunes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest.Respiratory Arrest,Or Ventncvlar Fibrillation W thout Showing The Etiology.On Not Abbreviate.Enter Only One Cause On To Death
A Line. Add AOGtinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition ResL4ng In Death) A. ENDOMETRIAL CANCER WITH METASTASES ONE YEAR
Cue<lt...Ce.m..e.06
Sequentially List Conditions. If Any,Leading To The Cause listed On 8.
Line A. Enter The Undelyny Cause(Disease Or Injury That Initiated a.cen�. o oe
The Events Resulting In Death)Last C.
o.,,, ....0„........„do
D. _
P a r.II.Enter Otte .n..... . . . ., .. ... •a:a,But Not Resutpng In The Lkoe yr'g Cause GMn In Part I 29.Was An Autopsy Performed? 0 Yes 0 No
TYPE 2 DIABETES MELLITUS,CHRONIC RENAL FAILURE,LEFT-SIDED CONGESTIVE HEART FAILURE WITH EF 25 30.Were Autopsy Finding AvavaGe To COndete The Cause Of Death? 0 Yes 0 No
31.Di0 Tobacco Use Contsbute To Death? 32. If Female: 33. Manner Of Death:
❑Yes ❑PiWaOly El No ❑unknown
0�p`Ou,awt . 0 n.we.i Ti,,,a o..th 0 u.enn"BN.,.r.,won it c.n ao.w 0 Natrat 0 Hormone 0 Accident 0 Penang Investgatgn
0,.a bob..eta e.w+in o...r.,.-ewe.Dub 9 wen Ter ant vs 0 Suicide 0 Cobb Not Be Determined
34.Or Of Injury(MatnDaylY ear) 35.Terse Of Injury 36. Place Of Injury(E.G..Decedents Home.Construction Site.Restaurant Wooded Areal 37.Injury At Wok?
0 Yes 0 No
38.Locasn Of Injury-Sam 38a.C wry Or Town 380. Street&Number 38c. APL NO. 38d. Zm Code
39.Desate How Injury Occurred 40. If Transoo cm Injury,spec tr
41. Sgnaure,Of Person Cer'ryg Cause Of Death: 42. Ceruier(Check Only One)
WILLIAM R.WELLS , BY ELECTRONIC SIGNATURE 0 Ce21yieg Phrsidan 0 Coroner 0 Henn OScer
43. Name.Adoess And Zip Code Of Person Cenfyig Cause Of Death: -- , 44.License Number 45. Da te Ce:led
•
WILLIAM R.WELLS ,510 NORTH MAIN STREET, PRINCETON, IN 47670 01017790A 10/02/2013
46.Add:gnat Funeral Service Provider. 47. Aids:
I
48. Signature of Local Heath Ottrer. 1, 49. For Registrar Only -Date Ftled(Ma+nDaytteart
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE �7 .\ I I I OCT 15 2013
AMENDMENT TO CE:RTIF.C7.TE OF DEATH(ENTRY OR ORIGINAL) I
a h\
tab- 19-)9-J01- 000u 73 i -pab
For
T n State Font 53395 ATTENTION ESTATE:The Social Seahry a is being requested by this state agency=order to pursue responsiGSry. Disclosure is voluntary and mere wig be no penalty for re!;sal.
IVRA-20