Death Certificate - Laswell, Jack W_10/22/2013 5 ...4..”:..:::-.E., :..,.. a .r . �.a> :,_ _ � -t:, I ', ,. .. ,...�,.-r...verve ,w 951596
/ 'A INDIANA STATE DEPARTMENT OF HEALTH
Sri CERTIFICATE OF DEATH
Local No 000867 EDR No 000000320314 State No 020199
1.De:weMS Legal Name(First,Mode.last) it Maiden Name(If female) 2.Sex 3. Tine Of Dean A Data Of Der(Aat VayMwr)
JACK W LASWELL MALE 08:17 AM 04/23/2013
- 78 menou Days Hass Mirages
Hospital
El Yes 0 No 0 Ur*now, 0 Martell 0 Emergency Delarwdere Curyeory 0 Dead an Artival
0 Hospice FaOy) ❑Decedent's Hone ❑Nursing HmeM1argbmn Care Facility
❑Oaw(Sparayt
•
11. Facility Name Of Not Ins[orton,Give Sweet and Number)
DEACONESS HOSPITAL INC
12.Cry Or Town Stare,And Zip Code 13. Carry Of Death 14. Matta Status At Time Of Dan
D Marred.But Separated 0 Divorced
EVANSVILLE, IN,47747 VANDERBURGH ®Naoeea He ver Mr ❑Onnpan
15.SetvMng Spouses Name 15a. Of WL1)Grve Maiden Last Name 16. Decedents Usual oaaprm 17. Kra OI Bust ssAnwaby
RETIRED LABORER FACTORY
16. Residence.Stare 18a.Carty lea. Ctya Toen
INDIANA GIBSON OAKLAND CITY
18c. Sweet And Number 184. Apt No. 18e.Zip Code 18t. Inside City Limes?
2353 S.CORD. 1250 EAST 47660 D Yes 0 No
19. Decedents Education 20. Decedent at Hispanic Own 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fellers Name(First Mille,Last) 23.MoCees Name(Fist,Mode.Last) 23a.Mothers Maiden Last Name
LUTHER LASWELL DELEMA LASWELL COLEMAN
24.IRWmanrs Name 24a.Relationship To Decedent 24d.Malmo Access (Street And Number,Cay,State,Zip Code)
1
STEVEN LASWELL SON 405 WEST ELM ST., HAUBSTADT IN 47639
25.Plain Of Deposmon
25a.Mewed Of aspostan 250.Race at Disposition(Name Of Cemetery,Crematory.Owner Place) 25c.Locator-Cry.Twos.And State
G BMW 0 amstron 0 Omaaon D Entombment I
El Removal From State
El Caw(Spray): AUGUSTA CEMETRY AUGUSTA, IN
26.Was Comer Created! 27. Name And Compete Address Of Fuwal Faoky 27a. Finial Hose License Huber.
®res ❑No LAMB BASHAM MEMORIAL CHAPEL, INC.,226 E.WASHINGTON STREET,OAKLAND CITY,
IN 47660 FH83005312
770. Snare Of Inde e Ftrierat 5 cc Licensee: 27c. License Nutter(a Licensee):
JERRY LEE BASHAM, BY ELECTRONIC SIGNATURE F001016589
Cause Of Death (See Instruction And Examples) Approxitate
28.Part I.Enter The Chain Of Events -Diseases,trans,Or Complimtions-Thai Directly Caused The Death Do Not Enter Terminal Everts naervat Onset
Such As Cardiac Arrest Respiratory Anal Or Vent:cam FiOMation With=Sinwng The Etiology.Do Not Abbreviate.Enter Orly One Cause On To Death
A Lime. Add Abeam]Lines If Necessary.
Immediate Cause(Final Disease Or Canadian Resting in Death) A SEPSIS MINUTES
oa
to w A Ce-ae-oq.
Seouerleg o y List C damns, If Any,Leading a
To The Cause Listed On B. URINARY TRACT INFECTION
Line A. Enter The Underlying Case(Disease Or Mpty That Iroda:ell °1tltor x'•r°`°-v 0e
The Events Resutlrg In Death)Last- C. CERVICAL FRACTURES
ova for As ACa-a.a06 -
D. MOTOR VEHICLE ACCIDENT .
Part II.Enos Omr$iovrat Condmgns CM.neuno to Death But Not Restyling In The Under/tog Case Can In Pat I 29.Was An Auopsy Pakom3V
❑Yes 0 No
NO 30.Were AV.opsy Finding Available To Candela The Cause a an
Dea?
❑Yes 0 No
31.Did Tobacco Use Connte To Death? 32.If Female: 33. Hornera Dean
❑Yin ❑ProOatlY®No ❑Unknown
D rs+s-xw-eve.- 0 raw...n..0o... 0 ter meet u eese s w..a V.crown 0 Nataf 0 Sent* 0 Accident 0 Peeing Infestation
0 se Await u nom-.ad.T.,-snot oven ❑w>.4 Anew ewe a e...s 0 Selode 0 Coed Not Be Determined
34. Date aMen(MmwVDaylYear) 35. Tineatlryuy 36. Place a busy(E.G..Decedent's Home,Cmsbuum Ste.RestatraLL bedded Arne) 37.Iryuy At Work?
04/09/2013 12:44 PM STREET D Yes 0 No
38.Loalim almTury-Stab I 38a Gaya Twos 380. Sweet 6NUnae 380. Apt NO. 380. 2y Code
STATE ROAD COUNTY ROAD 850 EAST
INDIANA OAKLAND CITY HIGHWAY 47660
39, Despite How lr'ry Owned 40. II Tranmdriaton Lary,S�eoy:
( Otao0o.e. D•.r�tiles....DOS.IRA"
MOTOR VEHICLE ACCIDENT
41. Signature,Of Person Cawtyrg Cause at Death: 42.Center(Check Only One)
ANNIE E. GROVES, BY ELECTRONIC SIGNATURE L7 Cemm>ing Pnysbsn 0 Cnw D Hetn Ott err
43. Name,Address And Zip Code Of Person Cetying Cause Of Derr 44. License Number 45. Dab earthed
ANNIE E.GROVES , 201 S. MORTON AVENUE, EVANSVILLE, IN 47713 NONE 04/26/2013
46.ACdoera Funeral Service Provider 47. 'Alas:
!48.SiguN d al re te Heath Maw. 49. For Registrar Only -Dab Fried(MerVDay/Yea:
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE APR 29 2013
I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
96;_)/4-3079W COD • LIqA-ceze---a(0-14-19- /loo- 000 y9i - Dap
"s State Form 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agercy in order to pursue responslbiaty. Disclosure is voluntary and there will be no penalty fce refusal
r Ste' W': NRA-20
AVOID IF:ALTERED OR`ERASED-NOT.VALID UNLESS CERTIFIED-BY-HEALTH DEP,RTM I•