Death Certificate - Lee, Glenda M_11/26/2013 ;atf=Eci, INDIANA STATE DEPARTMENT OF HEALTH _
°'`` CERTIFICATE OF DEATH
`: a~:' Local No 000560 EDR No 000000351469 State No 050045
1.De:eceets Legal Name airsL:4tda.Last) It) Maiden Name (ii female) 2.Sea 3. Time Of Team L. 2 are C•.Deatn 0 nTulDayliea:)
I GLENDA M LEE JULIAN r MALE 05:10 AM 11/03/2013
71 I _ 1 Days I he• tes I
D rospice.Fazday 0 paid--et-_m_ 0 M1_zicc-ore^_:n?•tern Care Fa:d;y
1 Yes 0 No ❑UrA nr ir. Irpaen: ❑Er_-eery D_ena:.mem Do:Patent ❑Dead on ArMal F l Coer(Sper;fi)
I iary Name (If::::IZ__ten,OF.e See at and R_m:er)
DEACONESS GATEWAY
12. City Or Town,Sate,one 512 Code 13.County CT Dean ad. Maual Status A:Tine Ol Deae.
Mane:❑Marne:,Out Seoaa:en 0 Divorced
NEWBURGH, IN, 47630 WARRICK v&rse: = verMarne: ❑urm.o
15. Suria-m Spouse's Name 15a.(If•V.1fe)3Ne Maiden.Las:Name 51. `erects::floral OSUCave:. 17. rice Of Eus:eaa&.puscy
JERRY LEE HOMEMAKER HOME
15.Resaen:a-State ._a. County 1St.City Or Tovn
INDIANA GIBSON OAKLAND CITY
15:. Street And Number 15d. Ant.No .Ee. be Coca :5`. Insi:e City Limits?
315 W. FIRST ST. 47660 3'Yee ❑Nd
19. Oceoeea Ecuasd'. 20. Decedent^t H6patic C4g'r. 21. De:ecen['s ice
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fdnerstame(FUSt 1.::cle,Last) 23.Notes Name(First.l.'ado!e.Last) 23a.Na:ne'a b'abn test Name
BILL JULIAN
MARIE JULIAN JONES
12d.Inlomanta Name 2aa.Relavonsnip To Decedent 2.Mang n eress (Street And Noma:.City.State,tap Code)
JERRY LEE HUSBAND 13115 W. FIRST ST.. OAKLAND CITY, IN 47660 1
I 25.Place v Disoosns. I
25a.Itetod Of D.spds.tcn 25:.Place Of Dsooston(Name Of Cemetery,Crematory,O'er Plate) - 25c.Lour.-City,Town,Ac_Sate --
E.:Siva! ❑Cremzvos 1_Donation. ❑Ertsmnett
❑Removal From State
• ❑One:(Sanity): MONTGOMERY CEMETERY OAKLAND CITY, IN
25.Was Coroner Cata_e_r 27. Nave And Complete Address Of FUneal Faulty 2]t) Funeral home!i=ese Noma:NC LAMB BASHAM MEMORIAL CHAPEL, INC., 226 E.WASHINGTON STREET, OAKLAND CITY,
0 IN 47660 FH83005312
274. Signature Of lndia:a Funeral Service Licensee 27:. License::ur her(Cf Licensee)f
JERRY LEE BASHAM , BY ELECTRONIC SIGNATURE IFD01016589
Cause Of Death (See Instructions And Examples) Aostrximate
2E.Pan.I.Enter The One:,Of Events -Diseases,Ir1uries,Or Complications-That Directly Caused The Deatn.Do Ncc Enter Ter.-cal E vens Interval: Onset
Seth As Cardiac Arrest,Respiratory Ares:,Or Ventricular Ficrilla:ion Witnout Snowing Inc Etiology.De Not AC:re.iale Enter Only One Cause On T.Dean'.
A Lire. Add Aoditnal Lines If Necessary.
I-meciate Cause(Final Disease Or Con^_.ion Resultry In Death) A. RESPIRATORY FAILURE I WEEK
Secuen:ially List ConcGms, If Any,Leading To Ire Cause L istei On E. RENAL FAILURE 1 WEEK
Line A. Enter i rte Underlying Cause(Disease Or lajpr:That Initiates
Ire Events Resultim,_In Deatn)Last C. ENCEP:HALOPATHY WEEKS
D.
Pan II.Enter Otner SionosamCouevoma Cun:no.c:o r Dear:?r:Not Resulting In Inc lieuen;in;Cause IPM In Pa-I I 29. Was A;_rosy Pe-famed? -
- ❑Yes No
NONE 13 . Were^-.__y g Avaaa_le To Cc-_._The Can_Of:_a..? FG Ye_ ❑Nc
31. Did Tozac^^Use C:nn:ata To Dea.i 32. If Female:
EA _ e ':Dean:
❑Ys ❑Pmdady L't UO stair. ue,.,.^000a...... ❑r-; s,r...IXaa.e _ -.-...v:..-•.:.e,.nn-ar.e suit e._al 0 R :._ 'L_I Aaricent. 0?ern Ines:yavon
❑E :, e❑C_..:e::Ee Deer:se::
3t). Dale 01Ijury(Mon:-JJayUear) 35. eneofInjury 1t)L36. . ' a Ireur.(_L Decedents^p = Ctnsnu':d _ Restaurant. Area) 9 _'Pp At Ron?
ND
3E. Lo_asu O•.Int_:.-.Szoe Ha. =,:y Dr Town 35L Steal 5 NUM:Er Sec. -....._. L_.v,__._
.,__.,.d_ em ly:c „.wee: - .>..x:.n::_:IY.ju:Y.Sos..- =
e. Co=arson n;Cause Of Dean: I-_. Cec Ge
eer e_�O:.li-=a_)
I ear PETER JOSHUA.JURAN . BY ELECTRONIC SIGNATURE I '? -::a. - --a..c f.et
'3. Na-e,Andress Cat_i:Code Of Perste Ce-'tiro Care^f heath: l 44. i-erue t::n__r I r_. _es Ca: :
_ I 44. !
PETER JOSHUA JURAN . 600 MARY STREET. EVANSVILLE. IN =77'7 101069256..A 1 /1/032013
I 45. Acsoual Funeral cerv'e Pro.roer: zs-
I
( E. Signature o'!ttai enact C.'.:e: Registrar Only -Da_Fre:telocra Data°a21.
RICKY B YE.AGER. VIA ELECTRONIC SIGNATURE I For NOV 0=2013
ALtENOMEN'T TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
aL- 14-18- 1101-1-a00 . ( 3 9 - 00 7 r
State Form 1 i EItTION ESTATE:Ine Social Security::is Dein:recuestec cy tris state agency in order to corsue resoc nsioS:y. Disclosure in voluntary arc;;ere will to no tenaay for refusal.