Death Certificate - Ray, James A_11/13/2013 INDIANA STATE DEPARTMENT OF HEALTH 1092426
CERTIFICATE OF DEATH
k� ') Local No 002186 EDR No 000000350936 State No 050795
1.Decedents Legal Name(Fist Middle,Last) la. Maiden Name (If female) 2.Sex 3 Time Of Dean 4 Date Of Death(MaevDayNear)
JAMES A RAY MALE 08:40 PM 10/28/2013
Hospital
❑Yes ( No ❑Unitgwn ®Inpatient❑Emergency Department Outpatient ❑Dead on Anal 0 Hospice Facility ❑Decedents Home ❑Nvrsnp Horne/Long-term Care Facility
❑Omar(speedy)
I
11. Fealty Name Of Noe Ins:Y-at Give Sweet and Number)
DEACONESS HOSPITAL INC
12.Coy Or Town,State,And lip Code 13.Canty Of Death 14.Mama!Status At Tine Of Death
0 ar wd M Earl s EVANSVILLE, IN,47747 VANDERBURGH Widowed 0 New Marred O Unknown
15. Suvrng Spouse's Name 15a Of Y&le)Grve Maiden Last Name 16. Decedents Usual Oaayaton 17. Kind Of Businessandusvy
KAREN RAY UNDERHILL RESTAURATUER RESTAURANT
18. Reside ce-Stye isa Coady 1So. Cry Or Town
INDIANA GIBSON FORT BRANCH
18c. Sweet And Number
184. Apt No. the. Zip Code :6f.Inside City Limits?
807 EAST STRAIN STREET 47648 0 Yes ❑No
19. Decedents Educaton 24, Decade:,t Of Hispanic Onyin 21. Decedents Race I '
SOME COLLEGE CREDIT, BUT NOT A
DEGREE NOT HISPANIC White
22.Fathers Name(First Mahe Last) 23.Mothers Name(First Midge.Last) 23a.Mothers Macen Last Name
GUS RAY JOAN RAY BOND
24,Informants Name 24a.RelationsNp To Decedent ' 245.Maing Address (Street And Number,City,State,Zip Code)
KAREN RAY WIFE 807 EAST STRAIN STREET, FORT BRANCH, IN 47648
25.Place Of Gaposian I
25a Method Of Gspostat 25b.Place Of Disposi9on(Name Of Cemetery.Crematory.Other Place) ' 25d.Locabm-Cu ,ry Town,And State
0 Basal 0 Cremators ❑Donaton❑Ermmoment
❑Removal From State
❑Omer(Specify): BAKER CEMETERY BOONVILLE, IN
28.Was Coroner Contacted? 27. Name And Complete Address 01 Funeral Fealty 27a. Funeral Horne License Number.
❑Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON,iIN 47670 1 FH83005671
275. Signature 01 LMana Funeral Sevice Licensee. 27c.license Member(Of Licensee).
JOHN W WELLS. BY ELECTRONIC SIGNATURE FD01009940
Cause Of Death (See Instructions And Examples) Appcoxbnate
28.Pan I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events . Interval: Onset
Such As Cardiac Arrest Respiratory Arrest,Or Ventricular Fibnllation Wtho l Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additinal Lines II Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A ACUTE RENAL FAILURE
D.to lb w•Conran 0f
Sequentially List Conditions, If Any,Leading To The Cause Listed On 8. UREMIA
Lies A. Enter The Underfyig Cause(Disease Or Injury That Initiated w.lo re. O"eO"
The Events Resulting In Death)Last C
Ow to lo-4.Carson Pt
D.
Part II.Enter Other Significant Condoons Contbuttrq to Death But Not Resuttrg In The Underlying Cause Gvin In Pan I 29. Was An Autopsy Perfoemed?I 0 Yes 0 No
CHRONIC KIDNEY DISEASE 30.Were Autopsy Finely.;Avadatie To Complete The Cause Of Death? 0 Yes ❑No
31.Did Tobacco Use CambW To Death? 32. If Female. 33.Marne Of Dean
❑ e ewwn vse e.r., O maw.At re.acts O wy.n sa eta.+yaw °b..CO Den ®Natural 0 Homicide O Acadea ]Pending eaestgatxn❑Yes ❑Probably 0 No ❑Unknown
❑Note..o,.R as emp,.n a c.n To I r.ea..Dim 0 tinny..•enoe.yaew rev nor r... ❑Suicide❑Could Not Be Determined
34. Date Of Injury(Mont/Day/Year) 35. Time Of Injury 38. Place 011ryury(E.G.,Decedents Home,Const ictan Ste,Restaurant Wooded Area) 37. Injury At Wort?
I ❑Yes ❑No
38.Location Of Injury-Sate 38a City Or Tam 35o. Street&Number 38c. Api No. Jed. Zip Code
39. Describe How Injury Omxred 40. If Transpceaton tjuy, ty.
po-s..oewsw Dee..'e. e.awe pis+tit
41. Sya:ure, Of Person Certtfythg Cause Of Death 42. Cer.Sw(Cnerk Only One)
JAMIE LYNN DAVISON , BY ELECTRONIC SIGNATURE 0 Certifying Physician ❑Corona ❑Heath Officer
43. Name,Adtress And Zip Code Of Person Certifying Cause Of Death' 44! License N:mter 45. Date Certified
JAMIE LYNN DAVISON ,600 MARY ST., EVANSVILLE, IN 47747 01069276A 11/06/2013
46.AtrLtataf Funeral Service Provider. 47. 'Akar
48. Spence of Local Hearn Of:cer. 49. For Registrar Only -Oath Filed(Mont/Day/Yea).
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE I NOV 07 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) I
a ;. a6 -,4-1q - ioa 000' ar56 -��
:24 State Form 53395 ATTENTION ESTATE:The Social Secunty a is being requested by ttlis state agency in order to pursue responsibility. Disclosure is voluntary arid there win be no penalty for refusal.
10a 11/RA-20 I
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