Death Certificate - Martin, Robert Earl_5/1/2014 ,/,tt.st`�e,, u_..� INDIANA STATE DEPARTMENT OF HEALTH _� 739937
: -'y " CERTIFICATE OF DEATH
• :- Local No 001305 EDR No 000000209026 State No 030907
1.Decedent's Legal Name(Fest.Mate.Last) tax Maiden Name(If female) 2.Sex 3 Time O!Deam 4 Date Of Dean (MontNOaylYear)
ROBERT EARL MARTIN MALE 23:04 07/12/2011
86 Months I Days Hass Matures
Hospital
0 Hospice Facility 0 Decedents Moore 0 Nursing Horne/Long-term Care Facility
0 Yes 0 No 0 Un;t'town 0 Inoauent 0 Emergency Department Ouyatem 0 Dead on Amval 0 Omer(Speciy)
11. Fa:oty Name(If Not Irtscm:oct,Give Sheet and Number)
DEACONESS HOSPITAL INC
12 City&Town.State,And Zip Cope 13. Carry Of Dean 14. Mental Status At Time Of Dean
Q Mama]0 Hared,But Separated ❑Divorced
EVANSVILLE, IN, 47747 VANDERBURGH WMawed ❑Never Marred ❑un'mown
15 Seri-lag Spouse's Name 15a. (If lWe)Grve Maiden Last Name 16. Decedents Usual Occupation 17. Kind Of Busnessnndustry
GERTIE MARTIN MARCUM ELECTRONICS MECHANIC GOVERNMENT
Is. Residence-Slate 15a County 130. City Or Town
INDIANA GIBSON OWENSVILLE
._c Street And Number 18d. Apt No. 18e. Zip Code lef Inside City Limits'
511 NORTH MAIN STREET 'I . 47665 O Yes 0 No
19 Decedents Education 20 Decedent Of Hispanic Omlin 21 Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22 Fathers Name(First Lillie,Last) 23.Mothers Name(First,Middle.Last) 23a Mothers Maiden Last Name
GEORGE MARTIN MACEL PEARL MARTIN JULIAN '
24.Infomn_nts Name 24a Relatonsrsp To Decedent 240 MAN Address (Street And Nanoen,City.State,Zip Clue)
GERTIE MARTIN WIFE 511 NORTH MAIN STREET, OWENSVILLE, IN 47665
I 25.Place Of Disposition
25a Method Of Disoosuon 25o.Race Cl Disposison(Name Of Cemetery.Crematory,Other Pfacej 25c Location-Ciy,Town,And State
❑' Burial 0 Cremation 0 Doramn D Entombment
❑Removal From State
0 over(Specify). OWENSVILLE CEMETERY OWENSVILLE. IN
25 Was Coroner Contacted, 27 Name And Complete Address Of Funeral FaoHY 27a Funeral Home License Number.
p yes No HOLDERS FUNERAL HOME OF GIBSON COUNTY, INC., 319 SOUTH MAIN STREET,
OWENSVILLE, IN 47665 FH89000021
27o. Signature Of Indiana rases!Serece Licensee: 27c License Number(Of Licensee):
RANDALL K DIKE , BY ELECTRONIC SIGNATURE IFD01010177
Cause Of Death (See Instructions And Examples) Approamate
28.Par,I.Enter The Cnain O:Events -Diseases,L'sunes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval. Onset
Such As Cardiac Arrest,Resciratoy Arrest,Or Venncular Fionllation WBhout Snowvng The Etiology.Do Not Abtrenate.Enter Only One Cause On To Death
A line. Add Additnal Lines If Necessary.
Immediate Cause(Fnal Disease Or Condition Resulting In Death) A AORTIC DISSECTION
Oa alai A„Cm,• • en
Secuentialy List Ccno,tions, If Any,Leading To The Cause Listed On B CARDIOPULMONARY ARREST
Line A Enter Tne Underlying Cause(Olsease Or Injury That Initiated p' i.ta..AC.o-..w.••.on
The Events Resulting In Deettrt)Last C
De.I.10.•••rr.,w•••m
D.
Pan It Enter Omer Siarafcant C0•'240s COrtr,ov:roe to beam Bo:Not Resaong In Inc Utberyi:52 Cause Ones In Pan I 29 Was An Autopsy Performed?
0 Yes 0 No
NOT APPLICABLE 130.Were Auopsy Endng Avaaaote To Complete Inc Cause Of Dean,
0 Yes ❑:fo
31. Dm Toward Use Contribute To Dear, 32 L'Fena'e: 33.Mama Of Dean:
0 Yes 0?rowdy I]NO y l...NPVn 0�e ierre xiex a,n..a 0 A.r_eui Teo 4004.4 0 v.F.y...eaF,Tw arm.2 pan Gen. O Natural 0 Honijde 0',cadent ❑Penang bKessgabcn
❑.+a e a Oros:. kern 0..t 0 era..,.euavasw2.,tie 05ulode 0 Could Not Be Deternsnec
34 Date Of Injury(MonthDa]rvea4 35 Time Of Ir.ury 3E. Place Of Injury IEG.Decedent's Home.Construction Ste.Restaurant Wooded Areal 37. Lryury At Wore,
0 Yes 0 No
3c.LOcason Ot Igor,-i ale 35a Cvy Or lewd 36b Street 8 Numcer ( 350 Apt No. led Zoo Code
39 Desaoe How Injury erurrec 40 If Transpafahon Lryay,Soeu. :
Oo...ve..e Ce...K.. Oe.ai..n Uw.tie.>n
41 Signature,Of PersonCerJyvr Cause Ce Dean 1 42 Center (Cheers Only Orel
HINA RAHMAN t BY ELECTRONIC SIGNATURE 0 Cer-tying Pnysioan 0 Coroner , 0 Hearn Officer
43 Name,Address=nor tic Cede G?erson Certt1va Cause Cr.Ceara: 44. License Nanber 45. Date Centred
HINA RAHMAN ,600 MARY STREET, EVANSVILLE. IN 47747 01068339A 07/15/2011
145 Accimnal Funeral Service Provmer. I 47. 'Arras.
45. Signature of Local'RealmOtticer. 49. For Registrar Only .Date Fled (MonnfDayfYe.I'.
RAYMOND W. NICHOLSON.JR.,VIA ELECTRONIC SIGNATURE JUL 18 2011
1 AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
i
. 1..-,aG,► `1-01 -404- (5o0.soa - oat
-u State Furth 53395 ATTENTION ESTATE'Tne Social Seajnty a is being reccested by this state agency en order to pursue responsbtty Disclosure is voluntary arc there will Oe no penally for refusal.
IVRA-20
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