Death Certificate - Wilson, David E_5/22/2014 INDIANA STATE-DEPARTMENT OF HEALTH 8 9 (41 U
° CERTIFICATE OF DEATH
Local No 000091 EDR No 000000383916 State No 020904
1.Decedents Legal Name(Fest.!bade,Last) Ia.Maiden Name(If femme) 2.Sea 3. Time Of Death 4. Date Of Death(MwttllDaynear)
DAVID E WILSON MALE 11:00 PM 05/05/2014
43 Months Days Hours Minutes 05/10/1970 EVANSVILLE, IN
9. Ever in U.S.Armed Forces? 10.11 Death Occurred In A Masora!: 10a. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Faulty ®Decedents Horne 0 Nursing Horne/Longterm Care Faulty
0 Yes 0 No 0 Unknown 01npatent 0 Emergency Department Ouyaient 0 Dead on Arrival 0 Other(Specify)
11. Faced Name(If Not Instwum,Give Street and Number)
504 EAST GIBSON STREET
12.City Or Town.State.Aral by Cade 13.County Of Death 14.Marital Slams At Time Of Death
0 Mimed 0 Clamed,But Separated 0 Divorced
HAUBSTADT, IN,47639 GIBSON 0 yesewed ®NeverMa^en 0 Unknown
15.Summng Spouse's Name t5a.(If Wfe)Gree Maiden Last Name 16. Decedents Usual Occupation 17.Kind Of BusvnessAndusby
TRUCK DRIVER TRANSPORTATION
16. Residence-State 18a. County lab. City Or Town
INDIANA GIBSON •HAUBSTADT
18c.Street And Number tea. Apt No. 18e. Zip Code teL Inside City Limas?
504 EAST GIBSON STREET 47639 Yes D No
19. Decedents Educatvon 20. Decedent Of Hnpa.c Ongn 21.Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(Fast!Addle,Last) 23.Mothers Name(Fist MSdae,Last) 23a.Mothers Maiden Last Name
MELVIN WILSON SANDRA SUE WILSON BOYLE
24.Informants Name 24a.Relationship To Dece ent 24b.Marling Address (Street And Numbe,City.State,Zip Code)
MELVIN WILSON FATHER 11972 SOUTH 525 WEST, CYNTHIANA, IN 47612
25.Place Of Disposition
25a.Method Of Disposben 250.Race Of Disposition(Name Of Cemetery.Crematory.Other Place) 25c.Location-City.Town.And State
0 Boom 0 Cremation 0 Doraton 0 Entombment
0 Removal From State
0 Omer(Speciryk ASBERY CEMETERY OMAHA. IL
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Fadkty 27e. Fungal Herne license Number.
0 Yes 0 No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168,FORT BRANCH, IN 47648 FH10900013
27b.Sgabue Of Indiana Funeral Service Licensee: 27c.License Number(Of Licenseek
ROBERT S STODGHILL, BY ELECTRONIC SIGNATURE F1301024378
Cause Of Death (See Instructions And Examples) Approximate
23.Pad I.Enter The Chain Of Events -Diseases,Injunes,Or Complications-That Directly Caused The Dean.Do Not Enter Terminal Events interval: Onset
Such As Cardiac Arrest,Respiratory Arrest Or Ven;ncvar Fiorittatian Without Snowing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. ATHEROSCLEROTIC HEART DISEASE YEARS
s4w10.a.4v.....e0n
Sequentially List Conditions. If My.Leading To The Cause Listed On B. LEFT VENTRICULAR HYPERTROPHY YEARS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated w°ro,..uw..,...am
The Events Resulting In Death)Last C. ATHEROSCLEROSIS WITH RUPTURED PLAQUE,CIRCUMFLEX CORONARY ARTERY
unnlu 4••v.....r.an
D.
Par A.Enter Other •n.. .t _ _ -Jr But Not Resulting In The Underlying Cane Glum In Part I 29.Was An Autopsy Performed? ®Yes ❑No
30.Were Autopsy Fining Available To Complete The Cane Of Death? 0 Yes 0 No
31.Did'COMM Use Canmbute To Death? 32. If Female: 33. Manner Of Death:
❑Yes ❑Probably❑No ®Unknown w P,ywnwm.e,5 Y- 0 Pse.n Atr...am..n 0 w w.a.A euPm.w wen.,47 Dun vane, 0 Nagral 0 Homicide D Accident 0 Penang Investigation
AAA.7a.(eaR.T.,,Y Oen To nre•b.0..e, 0 intro.,enyt.m we,.,The Pawl Yew 0 Suicide 0 Could Not Be Determined
34.Dam Of Injury(MonuvDayrvar) 35.Tine Of Injury 36. Place Of Injury(E.G..Decedent's Home.Convuaton Sue.Restaurant.Wooded Area) 37. Injury At Work?
• D Yes O No
36.Location n Of Injury-State 38a.City Or Tom 380. Sueft&Kanter 3BC. Apt No. Sad. Zip Code
39. Descnbe Maw Injury Occurred 40. If Transooutm Inryry, fy.
DO„nakn.v 0ra."'ea": Da+.ISart
41. Sgnature,Of Person Certiyng Cause Of Death: 42.Cecfier(Check Only One)
BARRETT W. DOYLE, BY ELECTRONIC SIGNATURE _ _ D CemMng Physician 0 Coroner ❑Heart Officer
43.Name.Adders And Zip Code Of Person Certfyug Cause Of Death: 44.License Number 45.Data Cerbed
BARRETT W. DOYLE , 520 SOUTH MAIN ST, PRINCETON, IN 47670 05/10/2014
46.Adf:Sanal Funeral Service Provider 47. -Alas:
4B.Sgnet'of Local Heath O°.tcer. 49. For Reglsuar Only -Dam Fled(MOnTVOaylYeak
BRUCE BRINK JR.VIA ELECTRONIC SIGNATURE MAY 12 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
96-1931- 304 .00x . 3a \-OD9
State�.e.
S� pF+enn 53395 ATTENTION ESTATE:The Social Secvnry:is being reouested by this state agency in order to pursue respansiD&ry. Disclosure is voluntary and there vat be no penalty for ra4sal.
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