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Death Certificate - Reavis, Juanita_7/8/2014 2t•7 4,./:-.'cir;,"'":1 I!! ;.4:', ,E.::", :-,•:.... 1 ::: 4a;3-•"!4-;i"V i\1_!.%-"'-'-s-.*1--m,•`."`::..:.;l'i._.,:Vt:t)-.•".','".:!`,-1I.'--.-. -,•1'-.'' ?,-;_:.5 e!,i!c•i. ,!1".-.-.5.--. ... %,3, i.1I.:",,;-, i:i z!-4 I.'I:s'-:-.! D:-. A,0.;'N--k,kT T..A-oA_k l_TE.:..D•::EPJ•"""t' R'.ZiaNA.1,E"".N T Q'F',;.I?T11<.!.LE1u.'t.AL T3- H ;i: a :-'::;':'i:t 4:"..:,4 : `vQt RifILA EVEIDATK ->c 1: : , P .:-.!„-•1.-:"---:-::1,:-1:„..7.!":":7.-,.;; ffi ; f "liPt IflpitV t ;1:' t ? , - - Local No 000941 . • EoFN )00000 3843641 e: StateSo'021631 .y... -:;j,:e-':"-fl c:`",-t,•,:::7:z I: :-: (1:Ci!Nedentte9alelene;ltekt.Milne.tekt)tv;;' ,,,,,..'''....“,,:, .;c”r4; ota:44aide5Name,(11 femae)..:.,..fa!' s i ,,,•:::, i!lip :..2.Seii,..-rt:i 3:Rvne Of Dean;:- , 4Date 01 Deed, (MontNDayelearr. ," . ROSE 4-'• _,...." '''.2'.. 1 ,c-- 'V' UANI t-,A E6 REAVIS t 1 ; Nr-.. .-:t. : ,.. ,t r• ;:-...rcA WEFINIER .:71-1"-/e,;;;;;Itr--r .rrci',--r..,.. FEMALE': t .01:05-PM/ ; ric-,.,•05/09/2014 .-4 . •: -, . -: 12;II Nato?Furred in A Hospiutl, 4,,,, ;,•. N,...,,..,zt '3...7-4,,i.,10e:It Ott,Occurred Somewhere Omer Tnen A Hospeal ........"; -;''' ` te .. •- .%. (I'C'' 'e'''''''•:•-'.7-1C;t. 0 irazateei..i 0.0;r:edents Horne• .0((rioting Hccieft3ng-terni dere cans&' • . So Yes 0 No.:a Unkikove' 0 InPabeie 0 Emergency Department Outpatera\(J Dead on'Arnval y "-" 7 - ;•; .•. ' - '.."- • ' -. 7 I •, . 7. 7i7 'i7 r" ‘- 'ir 11. Fealty Name(II Not Instaracc,Give Sleet and Number) :; i 1. 2-, --'< '- -,"- 72,--b.e 2: b 7:727 ; 3i.T MARY'S MEDICAL CENTER OF EVANSVILLE, INC • :: 11 . , ..12.Crly Or Town.State,And Zip Code -. • .• ' • 14,Mental Status At Time Or Death' -,., . - Et min/050 Mama:But Separated 0 Divorced -. ,-.-; VANSVILLE,IN 47750 • ' . it' -r,... c '.--:-.4./ ' ':-/. VANDERBURGH •••• . ..„, 0 Wdowed br'0 Never Istamed I 0 Unknorin ., , 415 Strviving Spouses Name,.. .. . ' " ." 15a. Of Wife)GNe Malden Last Name.'7,,,:.. - 7 5,-.' 16k Decedent's Usual Occupation' 17/ Kind Of Businessenclusey • T r-:' HOMEMAKER AND .. / HOMEMAKERAND 4., ICI-IAEL REAVIS - - c , r 5. ..% , ..-4 -4-. .• •••-: FACTORY / , . ' ' INDUSTRY ;: r, = . • ...: 118. Residence-State,. .' 7k , "..C, „Ciiic.. :Nef:•' ' 1 -'7‘.•''' ' .9')-- ' , , • . , ,. .. INDIANA -. ' . ' • GIBSON . -. r. .3-3' .,/ PRINeETO :-.N - /re --- . . .• , . , • , -190 Sreet An]Number '. -• , • ' : • , : ; - : . . • ;• i i i 'F. ''''724k ...:-4 t'" :- • . - . 857 NORTH COUNTY ROAD EAST 0 Yes 0 No 47670 - • 2./OME COLLEGE CREDIT:BUT NOT A ','S7-.' "t...,*:`-`•*>r-/:,-"- 4-7 ' 7.7'- ...• 7 --- -- • ' 7•- - - • -:?BEGREE'r. ' ..- 1 . , NOT HISPANIC ' j Whfle -. 1 22 Fathers Name(First klidree.Last) •' ' '' ' • ', ' i -< - 23.Mother's Name(Fast,Mild&Last) - 23a Momses Maiden Last Name t ' , :1 , . . . . . . . . , ,t HARLES WEHMER . , , '•,. . ,, -;$ :% it, OSIE WEHMER. . . . . SHANNON.. :7.24 Infonnant s Name " 24a.Reiaticesho To Decedent,::-... ---,' 24o,Maling Address (Street And Nurrat City,State,Zip Code) - .., , ri , . . . • ICHEI;LE WILLIAMS . . DAUGHTER' / ..-.rzr, : 8441/MANCHESTER COURT, EVANSVILLE, IN 47725 i . - .. i. r , r-r- s -3. 3.-1- 's..15i:•friiiibroirraar5--4;---/-,■ -• : - .; ' -- -, : - 25a Metod Of Disponce ; ' , . ! , 25s Place Of Dispoatuon(Name Of Cemetery,Cremakont OWer Place) . 25c.Locatcc%City:Town,And State , • 0 Basal'0 Cremation 0 Donaton 0 Eniombmard - ' : : ,' t k . . , . ,_. - - . . , . LJ!Removal From Silts ; 0&Mee liPeceY). "..-:: ' - • ' EVANSVILLE CREMATORY‘.':;,,-;;..-/'' „tr.":'1.,. EVANSVILLE, IN - • 29,Was Caner Contacted? , ; 27. Name And Complete Address Of Funeral Tapley -7:7- ......\,..:-. - 7 . , `, , 27a Funeral Horne license Number, ' • / 0 Yes 0110 HOME _ 1;....-f. . ;, !.:.... -: ; . i i : '. • " l. ' , . . ": . . . COLVIN FUNERAL HOME INC 425 N MAIN ST.1 PRINCETON, IN 47670 - -. FH83005671-- 27o Signature Of Indiana Relent SeriNe Licensee, • . .- : 5 , i -1, -:' i'l..%- :I:7'.i;'I- '..-....■ ..:::: '-: '., 27c License Number(Of License"): / 7 " •77 ?7 - -!CHARD DEAN HICKROD-, BY ELECTRONIC SIGNATURE.. .. ./ "%-rr•'',.":" . ''r; .I; ;-, •••• , FD01012153 .. . , " - .. ..-a Cause Of Death (See Instructions And Examples)\C'' -- ' ' . Appnosmia 28:Part I.Enter Tile Chain Of Event ',Diseases,1r:furies,Or Complications,That Directly Caused The'Death.'Do Not Enter Terminal Evems Intervat Onset - •Such As Cardiac Arrest.Respiratory Arrelt,Or VentricuLar Fibrillation Wtriout Shovisrig Tne Etiologi.Do NorAbbreviate.Ent&Only One CaUse On ' To Death . ,A Line. Add AddLnal Likes 4 Necessary. . , T 7,'- 'C\ ',7„. '.'"-.'z-sr--; ... ..: i: : . . -.. : , . ? t ? ; ! >- is: , . • Immediate Cause(Final Dis.ease Or Condition Resuping In Death) ', A SEPSIS : ; ; .. e .:-- , % • :' . , ' - TWO WEEKS ' -. ... . , . , /- . . . 1..,' Sequentially List Conditions If Any.Leading lathe The Cause Listed On /)13!' ACUTE RENAL FAILURE *.--7 ...., intr...A... c.., . . • . .., Line A•Enter The Underlying Cause(Disease Or Injkay That Initiated, „, . ?.. --..•-r-c.?>'1 :. :, t i ,`-`,. • ' • , . ...; The Events Restiting In Death)Last . .... • • , -. ' C. '',01ISTRUCTIvE SLEEP APNEA' :'? 3,f ., •.. - . • • . .. , ‘ . • 4 : 4._.;' ‘ tit! J! c-‘? ; t : = ' k. ! . • - , , , / . , , N D...,-HYPERTENsION. :.,..:.-. 3;4•\„. t. \ ; , „ Pan lk,Enter Olner So-4cent Cone:tens Cant, no to Deem Sea Not'learning In Tile sInclerrfing Cruise ornn In Pan i--•1,..„,,,f 2k.V.'s.An A....-topsi Pcilaanee7 , . . . ‘ ,- • :f-.7' ..... ' t' ,, e 30 YVere Autopsy Finding Ave:table To Ccmplete The Cause 01.Nall?, ' ' ' , '\ ONGESTNE HEART FAILURE • . . 31.Do Tobacco Use Cant byte To Dorn? •, r !I female. .,.......ii... 0:..,,....Ai Tnt 010:a-0 ISOCC; ra•0:470.4ValoT:42 CI,.CO 6..e . ID tjaeiral 0 Hocnicida :0 Accident.0 Pending Irrvestigaicnt Unkssotm a . •.. ; , . :- ,,,....- . 0.2,,,,,,.4,.„,,,,z,„p,,,,o,o4T Do,T.,1 Tar pot.Doe, IT Oda UnlmooSee %Woo Thu PIT,VW /. . 0 Sde 0 Goad Not Be DeterITIMed :3 Ora Of Injury(My:I:I/Day/Veal') ' . 33.Tene Of treaty t ' t ' 36 Place Of lieury(E G.Decetlenes Home,Constnicbcn Ste,Flastaurara,Weeded Am) -.37. [retry At Work?' .* -. . • . , , . 0 Yes , 0 No• .. : \ , .. 4-, .38 Location f INuri-State , ; ' 38a City C:Town', .4 b : i 180- Street&Number, :: .: ' ,' k % ':. 7.. .-- -..7, .s: ;.. -; ; . : `T7.77 7, .. , - . , 19 DeSaltle Hove Injurg Dcz.-ined • , , ,tt, It Transsionabco Injury.Neaty: ' •, \ ..r . 41. Signature.Of Pence Cersay47 Cause 0i beast - .14 SMAN ASHRAF ; BY-ELECTRONIC SIGNATURE - ‘"; t t /3. = •. >13 --: -.., .-=-:: i 0 Certifying Physkaan . 0 Coronet 0 men olar ' '43.Name.Address Ana Zip Code Or Person Cart:tying Cause CI Death. -7: 2- '' - :•-': i ; , - 44. license Miner, 45. Date Car-tea . . ....., , ...t SMAN ASHRAF •3700 WASHINGTON AVNEUE,.EVA•ISVILLEC-IN"47750 ..----; rt /:. . 01069741A' . -' 05/14/2014 6 AosaffunerlSermaPms,der.' c % .'" ..... --- % •:--'5.;% ,,./:-.132-3...5-.1.3.-t: ,3.; 3• ,c- . T‘N.. c = .... -, 'sr-- ..., ---.. 443 Sibrrkeure of Lobel Heals,OL.5cer. i::,. ,. -... -. / -, ..,. ,... ;-::.5., i• rt........;.•,,p, ...-7.7.,,F. •,-.,..---.., ' ::- 49.-For Registrar Only -Data Filed (Msieraylyear) .,. ,.. 71.OBEREKENNETH SPEAR,VIA ELECTRONIC SIGNATI5REs../%:,ic24/1L,-(-ct.._ 05/...-5'1;?.=g,:::- .-r_ •-, /: r -=MAY 152014 ;,,,s, ,r ..: /4 ; r 3 : r rr. .-.- ; / : 4 :r AmENDmENT•ropErunFicATE of..pEATIBENTRyoRpRicirrAt.), ; ,. ir , ; '5-, •. ,i -z ,, .-.- i 2,4 i .. .... '. „: '..... C',....-..C.ki 1 r„,g1.T./ ....jaulK.,itirpr.kr,-4.4q,!'v.i-,,,.,: •;!:-.-:-,„,' i . ; - - •!,.. 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F i ' :-, ;i ir ::::„11"171';71-ill --!:'-: ii".!..‘"ii-V..!:-.Cd111!:-.,::::: •t144 Form S..3395 jATTENTION ESTATE:The Social S .414 _a is being irebbie rid-b y this-sberai agency--ineciiKOrStizibeieipoNebifty7.;DiSciitsurets voluntarnd mini Clio 0-trio pianaltY for ietalakti.:itTkt:I:e;,:t....i ' .a WARNING::-Tok, --ORIGINAL:DOCUMENT HAS A mtn.motimaF3ACKGROUND'ON SPECIAL- SECURITY.17APER AND THE GREAT SEAL GF,THE STATEGFINDIANA ON BACK THAT"'.-;.. -OMORANGETO YELLOWnArli a 'RUBBED:ORI,,ACDOCLIMES/T HIDDEN •LOON FRONT.THAT APPEARS WCIE PHOTO COCIED2=4: -, rt\te.-..r'' •7..)