Death Certificate - Moit, Billie_9/20/2013 / - INDIANA STATE DEPARTMENT OF HEALTH 1U 9 U 4 9 9
I_, , CERTIFICATE OF DEATH
Local No 001805 EDR No 000000343420 State No 042261 .
1.Decedents Legal Name(First.Muddle,last) Ia. Maiden Name (If female) 2.Sea 3, Time Of Death 4. Date Ot Deeds(Mord4OaytYear)
BILLIEJUNE-MOIT BENDER FEMALE 12:42 AM 09/15/2013
89 Morena Days I Han Minutes
Hosp'al
0 Hospice Fact), 0 Deceder(s Home 0 Nursing Horne/Long-term Care Fealty
p Yes ®No 0 Unknown el octets 0 Emergency De:anrnent Outaatent 0 Dead on Anal 0 Other(Specify) _
11. Faosty Name (It Not Inst ato l Give Steel and Number)
DEACONESS HOSPITAL INC
12, Cy Or Town,Sate,And Zip Code 13.Cluny Of Death 14. Mental Status At Time Of Dear.
0 Martell]Married.But Separated 0 Divorced
EVANSVILLE, IN, 47747 VANDERBURGH i ®Wdowed p Never Mimed 0 Unknown
15.Surviving Spouses Name 15a. (II TM;e)Gne Maiden Last Name 16. Decedents Usual flncabon 17. Kind Of Busyness/Industry
RIVETER AIRCRAFT
15 Residence.State I 15a. County lip. Coy Or Town
INDIANA GIBSON OWENSVILLE
12c Sceet AM Number lad Apt No. 18e, Zip Code 151. Inside Cay Lime?
8015 SOUTH 750 WEST 47665 0 Yes 0 No
19. Decedents Education 20. Decedent O Hispwc Ongn 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 Mothers Maiden Last Name
WILLIAM BENDER EVELYN BENDER MOUTARY
24.Informants Name 24a.Relatianstp To Decedent 240.Mating Address (Street And Number,City,Sale,Zip Code)
LARRY W MOIT SON 4825 MESKERPARK DRIVE, EVANSVILLE, IN 47720
25.Place Cf Dispcsoon
25a.Method Of Ospuiaon 250.Place 01 Disposison(Name 01 Cemetery,Crematory.Other Race) 25c Loca:on•Cy.Town,AM State
S Brral 0 Cremation 0 Donation 0 Entombment
D Removal Fran State
p Other(Specify): ANITOCH CEMETERY CYNTHIANA, IN
26.Was Coroner Contacted? 27. Name And Compete Address Of Funeral Faosty Coroner Ha. Funeral Havre License Number.
p Yes 0 N HOLDERS FUNERAL HOME OF GIBSON COUNTY, INC., 319 SOUTH MAIN STREET,
OWENSVILLE, IN 47665 - - FH89000021
27o. Signature Of Indiana Funeral Service Licensee: v . 27c License Nube
nr(01 Licensee): •
RANDALL K DIKE , BY ELECTRONIC SIGNATURE FD01010177 . -
Cause 01 Death (See Instructions And Examples). - Approbate
2B.Pan I.Enter The Chain Of Events -Diseases,Iryuries,Or Compliratons-That Directly Caused The Death.Do Not Enter Terminal Events Interval, Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology,Do Not Abbreviate Enter Only One Cause On To Death
A Line. Add Addeial Lines E Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A ACUTE LEUKEMIA ACUTE
ea m to A..we•.,e.an
•
Sequentially List Cordl:sons, If Any,Loading To The Cause Listed On B.
Line A_ Enter The Underlying Cause(Disease Or Iniy That throated wuto e.ewo-w.,tie
The Events Resulting In Death)Last C
w.e,o n.w.a.,se PI
0
Part It.Enter Other 5iprvtcant Concoct*Curtnoutrq to Dead.But Not Resulting In The Underlying Cause Gvm In Pan I 29. Was An Autopsy Performed? B Yes 0 Na -
GASTROINTESTINAL BLEEDING 30,Were Autopsy Fetag Available To Complete The Cause a Death? pees 0 No
31. Did iocamo Use Contbute To Death? 32. If Female: 33. Manner Of Death:
0 r e.esan vrw eta v... p nnrvfai r...a owe. p se nerve s.Aerenv4+,.2 own down ®NabimI 0 H lode 0 Acodent 0 Pending lnveslgabon
0 Yes 0 Probably 0 No 0 Unknown
p ..awry.,ea w.m..e r aye ter ww sae.an 0wwww,e e,wreewe.,my en y.., 0 S.:ode 0 Could Na Be Determined
34. Date Of Injury(MonOVDaylYear) 35. Time Of Injury 36. Place Of Iryvy(E.G..Decedent's Home,Cons:rwion Ste,Restaurant Wooded Areal 37. Iryay At Wut?
p Yes p No
38.Location Of Injury-State 36a. City Or Town 380 Sweet&Ntcnber 30c Apt.No. 381. Zen Code
39. Describe How Inryry Occurred 40. II Trensponran bv.ry.Specify:
Ow-aware. path.„-'pet „ neeet Moss°
At Signature,Of Person CefttAng Cause Of Death: 42,Cer Sec (check C e,Ore)
ELVIRA CANE , BY ELECTRONIC SIGNATURE 0 Ceni tying Pysioan 0 Coon .0 Heath Owxer
43, Name,Address And Zip Code Of Person Ceruyug Cause Of Death: 44. License Nirober 45.Date CetSed
ELVIRA CANE ,600 MARY ST., EVANSVILLE, IN 47747 01072863A 09/16/2013
46.AddGoial Funeral Service Provider. 47. 'Akas:
45. Sgnatsire of Local Health O:Scer. 49. For Registrar Only -Date Feed (MontDay/Yer)t
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE SEP 16 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
State Form 53395 ATTENTION ESTATE:The Social Security a is being requested by Ws state agency in ceder to pursue responsibly. Disclosure is voluntary and mere wet be no penaly tot refusal.
S' • NRA-20
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