Death Certificate - Godwin Jr, Joseph Hubert_10/23/2013 THIS IS AN OFFICIAL COPYOF RECORD OF DEATH.ORIGINAL CORY-ON F-ILE AT.INDIANA STATE1DEPARTMENT:OF HEALTH g 4 5 410
o� INDIANA STATE DEPARTMENT OF HEALTH
oa4 CERTIFICATE OF DEATH
\ � Local No 002288 EDR No 000000293926 state No 054427
1.Decedents Legal Name (First Middle,last) 1a. Maiden Name 01 female) 2.Sex 3. Tune Of Death 4. Date Of Death(MOdvilayfYear)
JOSEPH HUBERT GODWIN JR MALE 08:15 PM 12/08/2012
72 Matte Days Hart Miadee 12/10/1939 I CHERRY VALLEY,AR
9. Ever Si U.S.Armed Faces? 10.If Death Canned In A Hosp6al: 10a. It Dem Occurred Somewhere Other Than A Hospital
0 Yes 0 No D Unknown 0 Inpatient 0 Emergency Determent Ontoalen 0 Dead an Anrval 0 Other(( Fwtty ❑Decedent's Hone ❑Nursing HwnNlonpterm Care Fadity
❑Other(Specs)/
11.Fealty Name(If Not InseWtim,Give Street as Number)
DEACONESS HOSPICE CARE CENTER
12. City Or Town,Stabs,And Zip Code 13. Canty Of Death 14. Mahal Status At Time Of Death
• 0 Maned 0 Maned,But Separated 0 Divorced
EVANSVILLE, IN,47747 VANDERBURGH 0 yid 0 Never Marred 0 Unknorm
15. Stavhing Spade's Name 15e. (If Wte)Grre Maiden Last Name 18. Decedent's Usual Ocapaum 17. Kind Of Buslesvindusvy
STREET ROD
ROSARAH IRENE GODWIN WIENERT MANUFACTURER AUTOMOBILE
18. Resideaa-State 18a. County 18h.City Or Town
INDIANA GIBSON OWENSVILLE
13c.Steel AM Number 18d. Apt No. 18e. bp Code 16f.Imde City lima?
302 NORTH FIRST STREET 47765 0 Yes 0 No
19.Decedents Educikn 20.Decedent Of?asperse Odgeh 21.Decedents Raw
9TH- 12TH GRADE; NO DIPLOMA NOT HISPANIC White
22.Feeler's Name(First Middle,Last) 23.Mother's Name(First Made,Last) 23a.Moths Maiden Last Name
JOSEPH HUBERT GODWIN SR MARY SIBYL GODWIN I VAUGHN
24.Inbnnants Name 24a.Relationship To Decedent 24b.Mating Address(Sleet And/Amber.City,State,Zip Cade)
ROSARAH IRENE GODWIN WIFE 302 NORTH FIRST STREET,OWENSVILLE, IN 47765
25.Race Of Disposdgn
25a.Method Of Disposaan 250.Place Of Dispesiton (Name Of Cemetery,Crematory,Other Race) 25c.Lector'.Coy,Town.And State
0 Btnal O Cremabn 0 Daemon 0 Entanbnent
❑Removal From State
0 Other(Sperry): EVANSVILLE CREMATORY EVANSVILLE, IN
26.Was Came Canoed? 27. Name And Complas Address Of Fulani Fealty 27e Faieral Hone License Number,
Yes No HOLDERS FUNERAL HOME OF GIBSON COUNTY, INC., 319 SOUTH MAIN STREET,
0 OWENSVILLE, IN 47665 I FH89000021
27b. Signature Of Indere Fu war'Service Licensee: 27c. License Number(a licensee):
RANDALL K DIKE, BY ELECTRONIC SIGNATURE ,FD01010177
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Chan Of Events -Diseases,Injuries,Or Complications-That Dvecty Caused The Death.Do Not Enter Terminal Events Intervat Onset
Such As Cardiac Arrest Respiratory Arrest,Or Ventricular Fibrtlation Wihoui Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Addainal Ins If Necessary.
Immediate Cause(Final Disease Or Condition Resitting In Death) A. METASTATIC NON-SMALL CELL LUNG CANCER 8 MONTHS
- -e-wi64etegre Cp
Sequeniafy List Ca,dains, If My,Leading To The Cause Listed On et ace lc(Or M A c.-e
line A. Enter The Undery'rg Cause(DiePave Or Injury That IMiated
The Events ResltWng In Death)Last C_ •
ow top r•Comae."CO
D.
Part LL Enter Oter$1uvfcmt Cond:xns Connbta ng to Death BU Na Resilerg In The Underlying Cause Conn In Pan I 29.Was An Autopsy Performed? DYea 0 N
PULMONARY HYPERTENSION 30. Were Autopsy Fndtrg Avatable To Complete The Cause Of Death? 0 Yes 0 No
31. Did Tcacoo Use CantWSe To Dean? 32.If Female: 33. Mama Of Death:
0 Yes ❑PreDWy❑No UnHSwn 0 Net Pains.vice,Pr not D w.v.+At m.a p.m 0 nee bent u Prot..Ye.u Dent nom ®Naenal D Homicide 0 Acodem D Pendug nvestgabon
0 cn yawn u Paved o twin.I rare.o4., 0 iwv.n a once.Yea the hit Yon 0 Secide 0 Cold Na Be Determined
34. Data Of Injury(Month/Day/Year) _ 35.Time Of Injury 38. Place Of Injury(E.G.,Decedents Home,Consoicdton Ste,Restaurant 4\boded Ant) 37.Irjsy Al Won?
D Yes 0 No
38. Lawtian Ofvjtry-Slab - 38e C.ty Or Twin 35b. Sleet 8.Writer 39c.Apt No. 38d. Lp Code
39. Describe How lnjayOmned - UT O , aO a+ • r OPan Ores newer
41. Sipsaue,Of Pathan Cartiyng Cause Of Death: 42.Ceo er(Cleat Cady Die)
CHRISTOPHER BRADEN , BY ELECTRONIC SIGNATURE 0 centring Physician 0 Coroner 0 Hearth 06cer
43. Name.Address AM bp Code Of Person Cenyi g Cause Of Death: 44. License Number 45.Data CetSed
CHRISTOPHER BRADEN ,4055 GATEWAY BLVD, NEWBURGH, IN 47630 02003326A 12/10/2012
48.Aodoona Funeral Service Provider. 47.'Akan:
48. Signature of Local Health O3cer 49. For Reglstnr Only -Data Fled(Month/Day/Yes):
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE DEC 10 2012
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
a�-I -ODD-3?3-0Ra
!JO:,State Face 53395 ATTENTION ESTATE:The Serial Security tl is being retested by this state agency Si order to pursue responsibity. Disclosure is voluntary and there veil be no penalty fa refiner
ATTENTION
\ ,� Pros) r " '
e.VGIO IF ALTERED OR