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Death Certificate - Nixon, Charles M_12/11/2013 c-� 1 i ``- � w INDIANA STATE DEPARTMENT OF HEALTH 10 2 2 0 3 0 y CERTIFICATE OF DEATH k".rk, Local No 000598 EDR No 000000355043 State No 053628 1.Decedents Legal Name'(First L e d a e,Last)‘ gr r.'.- 1a.Malden Name(If female) 2.Sea 3. Time Of Death 4. Date Of Death(MdntDayflew) . tom-srrr,:�, CHARLES M NIXON ' -. L".10,,?z MALE 12:09 PM 11/23/2013 al 1 41 �./-: 7 ,'•4'I ❑Hospice Facity ❑Decedent's Hdx Nu 0 Yes'0 No D Unknown ®innate'•-0 Emergency DepaJmenl Outpatent 0 Dead on Arrival Nursing Hor:meA6Ribm Care Parity r.,._,..•.f_ :i..r_-.,C.aS Street ❑Outer(spGbfy> I 11_ Fa:dry tame:II/Not Ursaw•vowl GAe Street aid Number) DEACONESSTGATEWAY:> ;�=. '-'X 12.Ciy Or.Toywn;SUS,And alp Codes 13.County Of Death 14.Mental Stalls Al Time Of Deem• al.r.- .. 1 t I y„ •.• >:G r l • • ) = ®Memel❑Married,But Separated ❑Divorced NEWBURGMIN;47630 Z.,' -n: :3.:'ir' - WARRICK D Widowed D Never Martel 0 Unknwm 15. Surviving Spouse's Name 1 15a.(If Wde)Give Maiden Last Name 16. Decedent's Usual Dccupaoan 17. Kind Of Bustness/Industry RITA J NIXON MAYER MECHANIC 1 AUTO MECHANIC if Residence-Statee-r..r- - 18a. County I . City Or Town INDIANA -`'$• , GIBSON FORT BRANCH 15c. Street And Number • 18d. Apt No. lee. Zip Code 18f.Inside City Limits? 206 NORTH HULL STREET 47648 0 Yes ❑No 19.Decedent's Education 20. Decedent Of lksparic Ogn 21. Decedents Race HIGH SCHOOL GRADUATE OR GED COMPLETED NOT HISPANIC White 22.Famer's Name(First Middle.Lan) 23.Mould's Name(Fist(Addle,Last) 23a.Mother's Malden Last Name OATLEY NIXON PERNA NIXON RAINEY 24.Wentants Name 24a.Relatonsnip To Decedent 24b.f:airg Address (Street And Number,City.State.bp Code) RITA NIXON SPOUSE 206 NORTH HULL STREET, FORT BRANCH, IN 47648 25.Place Of Disposition I 25a.Method Of Disposition 256.Place Of Dispositon (Name Of Cemetery.Crematory,Other Place) 25c.Iodation-City,Town.And State D Burial ®Cremation 0 Donation 0 Entombment D Removal From State D Other(Speof PIERRE FUNERAL HOME EVANSVILLE, IN 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Faculty I 27a. Funeral Hon's License Numbers D yes 0 No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 -FH10900013 2T6.Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee): ROBERT S STODGHILL ,BY ELECTRONIC SIGNATURE FD01024378 Cause Of Death (See Instructions And Examples) Approximate 28.Part I.Enter The Chain Cli Events -Diseases,Injuries.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset Such As Cardiac Arrest,Respiratory Arrest.Or Ventnauar Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death A line. Add Addltinal Lines H Necessary. Immediate Cause(Final Disease Or Conoibon Resulting In Death) A. RESPIRATORY FAILURE 0 a.eio...ra...,...M Sequentialy List Conditios, If Any.Leading To The Cause Listed On B. CONGESTIVE HEART FAILURE 10 YEARS Line A. The Cause(Disease Or Injury That initiated p..<164.GSyw on Tr.e Events R esulting In Death)Last C. CORONARY HEART DISEASE 10 YEARS po-eio 5..rte......ob D. Par.II.Enter Omer$gn:pant ConOtgn5 Conlibutno to Dean But Not Resulting In Tne Underlying Cause Ginn In Pad I 29.was An Autopsy Performed? DYes 0 No 30. Were Autopsy Findug Avalede To Complete The Cause Of Death? D Yes D No NONE 31. Did Tobaoo Use Contribute To Death? 32. II Female: 33. Manner Of Dean: ❑yes ❑Probably D No 0 Unknown D'.ev •9.uiexw ”•• D rv...,••a,r.,.a owe D,a,n..�..eww.a.,.nwe..ra o..o o... 0 Natural D Homicide D Accident 0 Pending Investigation 0,a, . ,.a o...T.,,..e...o.... D en.s..n won..,n.Pa a Vs D SWide D Could Not Be Determined 34.Date Of Injury(MontntDaylYear) 35. Time Of Intry 36. Place Of Iryury(E.G.,Decedent's Herne,Construction Site.Restaurant.estaurant.wooded Areal 37.Injury At Won? Dyes DN0 35.Location Of Injury.State 38a.City Or Town 38b. Street a Number 38c. Apt No. 380. Zip Code 39. Describe How Injury Occurred 40. If TransoMa on Injury,S fr Der,le,,-s Dr•ss�e. L °p- 001wI•wr.) 41.Sgnature,Of Person Cendydg Cause Of Dean: 42.Cen.Ser(Check Only One) WARD MARSHALL NEFF, BY ELECTRONIC SIGNATURE ®Cer:fying Phi/suan D Coroner ,D Heat«seer 43. Name,Address And Zip Code Of Person Cercfyn9 Cause Of Dean: AA License Miter 45. Date Centel WARD MARSHALL NEFF ,4015 GATEWAY BLVD. 3RD FLOOR, NEWBURGH, IN 47630 01032825A 11/25/2013 46. Addamal Funeral Service Provider: 47. •Akers: 48. Signature of Local Heath purer. 49. For Registrar Only •Date RJea(MOniNDaylyear r RICKY B YEAGER,VIA ELECTRONIC SIGNATURE I NOV 25 2013 AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) I O?6-Iq-j -3oa- DOD- 'ix -cob a6-r'8ab-4fl0-iss0,2• p'lb -0aC &et,-19-lq-da° - POO .763fk25 a6 -1q-A-a©o -coal air?-Das- _ ,d State Form e Fo 53395 ATTENTION ESTATE:The Social Secunty i is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penally for refusal. ' • IVRA-20 I nroS)