Death Certificate - Lavanway, Alvah Stephen_12/4/2013 • 1092703
1 CERTIFICATE OF DEATH
�k = Local No 000197 EDR No 000000355225 state No 053934
1.Decedent's legal Name(First.Middle,Last) 1a. Maiden Name(It female) 2.Sea 3. Time Of Death 4. Date Of Death(Mont/Day/Year)
ALVAH STEPHEN LAVANWAY MALE 08:30 PM 11/23/2013
Nursing Horne/Lag-term Care Fealty
(]Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Oepannent Oul,atern 0 Dead on Arrival 0 other(speedy)
11.Fatly Name(If Not L sotutm,Give Street and Number)
4009 WEST 75 SOUTH
12.GNP Town,State.And Lp Code 13.Canty Of Death 14. Mental Status At Time Of Death
®Married 0 Marred,But Separated ❑Di.Clted
PRINCETON, IN, 47670 • GIBSON 0 WdOw0d 0 Never Maned 0 Unknown
15. Sulviwg Spouse's Name 15a. (It Wde)GNe Maiden Last Name 16. Decedent's Usual Occupation 17. Kind Ot Secrets/Industry
TAMARA LAVANWAY RODENHOUSE CARPENTER CARPENTER
18. Residence-State 18a. County 190. Cny Or Town
INDIANA GIBSON PRINCETON
18c. Street And Number 180. Apt No- tae. Lp Code 1St.I,tside City Linua?
4009 WEST 75 SOUTH 47670 0 Yes 0 No
19.Decedents Educaaon 20. Decedent Of ltispanic Onga 21. Decedent's Pace
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(Fis(Made,Last) 23.Mothers Name(First.Middle,last) 23a.Mothers Maiden last Name
ALVAH STEPHEN LAVANWAY PHYLLIS LAVANWAY COGAR
24.Warrant's Name 24a.Reatorstip To Decedent 245-MaArng Address(Street And thumper,City,State.Lp Code)
TAMARA LAVANWAY WIFE ,4009 WEST 75 SOUTH, PRINCETON, IN 47670
25.Place Of Disoositon
25a.Method Of Dee:Mem 250.Place Of Disposition (Name Of Cemetery.Crematory.Other Race) ' 25c.Locaton-City,Town,And Sate
0 Banal 0 Cremation 0 Donator 0 Entombment
0 Removal From State
0 Omer(Soeofyk EVANSVILLE CREMATORY EVANSVILLE, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Fad[ty 27a. Final Home License Number
0 Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27o. Signature Of Irtoana Funeral Service Licensee: 27c.License Number(Of Licenseek
JOHN W WELLS, BY ELECTRONIC SIGNATURE FD01009940
Cause Of Death (See Instructions And Examples) Approximate
23.Pan I.Enter The Chain Of Evens -Diseases,In uses,Or Complications-That Directly Causes The Death_Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest.Or Ventialar Fibntaticn Wthout Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A tine. Add Addtinal Lines H Necessary.
Immediate Cause(Final Disease Or Condition Reselling In Death) A. STROKE WITH LEFT SIDE PARESIS AND SEVERE DYSPHAGIA 3 WEEKS
M eta...ravine 0,1
Sequentially list Conditions, If Any,Leading To The Cause Listed On B. RESPIRATORY FAILURE 1 WEEK
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated �•ro •a,�om
The Events Resulting In Deal,)Last C.
a.eto...-ce4.9..e01
D.
Part U.Enter Other -•r_5cat • 4. ..s • l,• • •to Death.But Not Resritng In The Underlying Cause GMn In Part I 29.Was An Autopsy Performed? Dyes 0 No
SEVERE CHRONIC OBSTRUCTIVE PULMONARY DISEASE 30.Were Argosy Finding Avaaade To Complete The Cause Of Dean? 0 Yes 0 No
31.Did Toeece°Use Cdnsiatte To Deal,? 32.If Female: 33. Marne Of Death:
0.,4 4.n- 0 e.r.emsma of cut 0••..,.e,..an P.n.:Mfwa..:aryl 01:4C 0 Natural 0 Homicide 0 Accident 0 Pendog lnestgabon
0 Yes 0 Probably 0 No 0 Unknown
❑ratv,.rye.e,A=•.:+.nsn:=+taw..n..:. ❑u.,a•.vorw,w:..Ts.=.....• ❑Suicide❑Gad Not Be Detertrined
34. Dam Of I ry(Mon •DayiYear) 35. Time Of Injury 36. Place Of Injury(E.G..Decedents home,Cmsotrction See.Restaurant Wooded Area) 37. bp)/At wort?
0 yes 0 No
38.Lccalon Of Injury-Sax 38a.City Or Toxin 35b. Street&Number 38c. Apt.No. 38d.Lp Code
39.Desmbe Pow Injury Occurred 1 . 40. It Transporation injury.
41.Signature, Of Person CerNyi rig Cause Of Death: .. t 42 Cene S (Check Only One)
MOHAMMED ARFAN ALLAW, BY ELECTRONIC SIGNATURE 0 Ger_ying Physician 0 Conner 0 Heats Oficer
43.Name,Adores And La Code Of Pelson Cert:ycg Cause Of Cleat:: f 44.License Number 45. Dam Can-led
MOHAMMED ARFAN ALLAW ,4015 GATEWAY BLVD,STE 3010,NEWBURGH;IN 47630 01045554A 11/26/2013
46. AbdoM2l Funeral Seance Provider: t \ 1 - 47_ ••VS:
48. Signature of Loral Heat 0:5cer 49. For Registrar Only •Data Feed(Mon.JDayffeak
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE • NOV 26 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
i.:a6- I I -Ib-aOD -00 Li. 133 -() '7
d __to For
:d State Form 53395 ATTENTK)N ESTATE:The Social Se:tiny u is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there wit be no penalty for refusal.
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