Death Certificate - Deal, Wayne T_6/23/2014 THIS ISS AN'OFFlCIAL COP.110 D 0 Df EATH ORIGINAL�COPYDN'FIL'EfAT INDIANA STATEIDEPARTMENT,OPHEALTH
3^'R4\ INDIANASTATEDEPARTM 1 S 1078641 ily
i \ CERTIFICATE OF DEATH
` %J Local No 000086 • - . EDR No 000000383204 State No
1.Decedents Legal Name(Fes,M1f0Ire.Last) la.Maslen Name(If female) - 2.Sea i Time Of Death I. Date Of De=(MbntiDayfYear)
WAYNE T DEAL . • MALE 10:38 PM 05102/2014
• 73 Months Days Hours Minutes 05/05/1940 MOUNT CARMEL, IL
9. Ever in U.S.Armed Forces? 10.11 Death Occurred N A Hospital. • 10a..11 Death Occurred Somewhere Other Than A Hospital
0 Hospice Faciy 0 Decedents Home 0 Nursing Horne/Long-term Care Fealty
0 Yes 0 No 0 Unknown 0 Irpatent 0 Emergency Decartnent Ouyatent 0 Dead on Amval Q Other(Sperpy.)
11.Fatly Name(If Not nstsitom,Give Street and Number)
6879 SOUTH 550 WEST •
12.City Or Ton,Sate,And Zip Code 13.Cony OdDeam 14.Mantel Status At Time Of Death
0 Marled 0 Marred,But Separated 0 Divorced
OWENSVILLE, IN,47665 GIBSON 9 Wbowed 0 Never Marled 0 Unknown
15.Suntory Spouses Name 15a.(If W:G)Give Maiden Last Name 16. Decedents Usual Occupation 17. Knd Of Busnessln dusty
GIBSON COUNTY HIGHWAY
GWENDA DEAL CASKEY DEPARTMENT LABOR
18. Residence-Sate sea.County 18b. City Or Town
INDIANA GIBSON OWENSVILLE
18c.Steel And Number 18d. A0L No. 18e. Zip Code 1Sf. Inside CM Limits?
6879 SOUTH 550 ROAD WEST 47665 Q Yes N No
19. Decedents Education 20. Decedent 01 Hispanic Origin 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Father's Name(First Middle,Last) 23.Mothers Name(First Middle,Last) 23a.Mothers Maiden Last Name
OLLIE DEAL GERALDINE DEAL WRIGHT
24.lnbman's Name 24a.Relationship To Decedent 24o.Wing Address(Sleet And Number,City,Sate.Lp Code)
GWENDA DEAL WIFE 6879 SOUTH 550 ROAD WEST,OWENSVILLE, IN 47665
25.Place Of Disposition
250.Method Of D¢asoa 250.Race Of Disposton(Name Of Cemetery.Crematory.Other Place) 25c.Locapa-City,Tan,And State
0 Burial 0 Cremation 0 Doraton 0 Entombment
0 Removal From State
0 Other(Specify): CLARK CEMETERY OWENSVILLE, IN -
26.Was Canner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number,
0 Yes 0 No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168,FORT BRANCH, IN 47648 FH10900013
27b. Signature Of Indiana Funeral S.n:u.Licensee: 27c.License Ntmoer(Of Licensee):
ANDREA LYNN VINCENT, BY ELECTRONIC SIGNATURE FD21400005
Cause Of Death (See Instructions And Examples) Approximate
25.Pan I.Enter The Chain Of Events -Diseases,Injuries.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Soar As Cardiac Arrest.Respiratory Arrest,Or Ventricular Fibnlation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Addninal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. GASTRIC ADENOCARCINOMA 8 WEEKS
b.era A..Con.a-,n D9
Sequentially List Conoi5ons, If Any,Leading To The Cause Listed On B. HYPERBILIRUBINEMIA 8 WEEKS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated pi,elo..Ae:..a....om
The Events Resulting N Death)Last C. HYPERTENSION SEVERAL YEARS
cv.e10,..Ace .aA on
D. NORMOTENSIVE ENCEPHALOPATHY SEVERAL YEARS
Pa.II.Enter Other Scntcant Conduces Controuttno to Death But Not Resultng In The Undedyng Cause Galvin In Part I 29. Was An Autopsy Performed? 0 Yes 0 No
DIABETES MELLITUS 30.Were A11.01:67 Finding a
Finding Avaiade To Complete The Cause Of Death? Q Yes 0 No
31.Did Tobacoo Use Conmbe:e To Death? 32. II Female' 33. Manner Of Death:
Yes ❑Probably❑NO 0 Unknown
0-n.n°...'vns.e.r.. 0 P,rte T...ao..w 0 w.n.a.w u nea..x we.,Az oe.ac..e 0 Natiral 0 Hocicide 0 Accident 0 Pendig Icvestgaion
ID 0 Mamma,..o-.n.aw A,o.nr.,,a 4440444.4 0 t..e.,a e..r.ewe.T.per,., 0 Suicide 0 Coed Not Be Determined
34.Date Of injury(M cnttDay(Year) 35.Time Of InNry 36. Pace Of Injury(E.G..Decedent's Home.Consou n Site.Restaurant.Wooded Area) 37. Iryuy At Worm?
OYes 0No
38.Location Of Injury-State 38a.Cry Or Torn i