Death Certificate - Reeves, Clarence L_7/24/2014 a t "#4 INDIANA STATE DEFRTMENT,OF HEALTH -
CERTIFICATE OF DEATH
l Local No 000359 EDR No 000000394459 stateINo 032082 - - `
I.Decedent's Legal Name(Hat,Middle,Last) la. Maiden Name(If fer..ale) '" 2.Sea 3. Time Of Dena ' 4. Date Of Dear..(AfntdOaytlear)
CLARENCE LANDON REEVES MALE 11:32 AM 07/11/2014
Armed Forces? 10.I:Death Oauned tr.A Y.osoial: :9a. If Death Occurred 5or.,e.snere Other Than A Hospital
!� 0 ❑Hospice Facasy ❑Decedenrs Hoax ❑Nursing Home/tong-term Care Fxiy
y Yes ❑No ❑UnMOUn 0 L parent 0 Emergency Derailed ent Outhatent 0(lead on ATm'al F,Curer(Sreoty)
j11.Facty Name(If Not Institution,Give Street and Numcer)
9 DEACONESS GATEWAY
12.Coy Or Town,State.And Zr Code 13.Cducy Of Dean 14 Marital Satin At Tae C.beam
r0 Maded 0 married.But Separated 0 Diorcen
N EV•/BURGH, IN,47630 WARRICK
0 Widowed 0 Never Mato-- 0 Un.nown
15.Sunning Spouse's Hairs tSa. (I(NVe)Gne ld3idec last Name 16. DttmenCS Usual OccupaSC: 17. Kind Of Bus'tnsssllndesvy
SANDRA REEVES DEAL TRUCK DRIVER COUNTY GOVERNMENT
13. Resdence-Sax lEa. County 160. City Or Town
INDIANA GIBBON PRINCETON
:SC. Street And Number IBe. Apt,N.o. 16e. Zip Code 161. Inside City Lints?
j
4869 WEST 125 ROAD SOUTH 47670
0 Yes CD'Na
19.Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fa•:errs Name(e lt.k:a'?,last) 23.Morsel's Name(First,Lecdle.Lau) 23a.Mnme s Maiden last Name
ALBERT REEVES DORIS ATTENBAUCH KEENE
24.lestcemasts Name 24x.Relationship To Decedent 240.Ndaing Address (Street And Number,City,State,Zip Code)
SANDRA REEVES WIFE 4869 WEST 125 ROAD SOUTH, PRINCETON, IN 47670
25.Race Of Disposition
25a Mcmod Of Disposition 25b.Place Of Drspcsitgn (Name Of Cemetery.Crematory,Other Place) 25c.location-City.Town,And State
O Burial 0 Cremation 0 Donation 0 Entombment
D Rem oval From State
D Omer(Specify): MAPLE HILL CEMETERY PRINCETON, IN
26 Was Coroner Contacted? 27. Name And Cdr.FIe:e Address Of Funeral Fatty 27a. Funeral Home!kmse Number,
❑Yes 0 No DOYLE FUNERAL HOME, 520 S MAIN ST, PRINCETON, IN 47670 FH10400010
27D. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
B.ARRETT W. DOYLE, BY ELECTRONIC SIGNATURE FD29500009
Cause Of Death (See Instructions And Examples)
Approximate
On
23.Pad I.Enter
rdia The Ct. In so Of Events -Diseases,Or Itic:lar, io Or Complications
nos-That Directly e Cauogy The Death. e-Not Enter Terminal Cause Interval: Onset
Such As Cardiac Arrest. es If Necessary
Arrest,Or Ven;rigWa:FOriaa;ion VNnout Snowing The Etiology Do Not Abbre'nat?.Enter Only One Cause On To Death
A Line. Add Add,:dal Ries If NegesSary
Immediate Cause(Final Disease Or Condition Resulsnc In Death) A. METASTATIC LUNG CANCER
G.el4'u.ies.->t-G+
Sequentially List Conditions, II Any.Leading To The Cause Listed On B.
0..alo y+w. ...^p
Tire v Enter Resulting Tne ng Indying)Cause(Disease Or Injury Tnal Initiated
'
The Events Resulting 1.�Death)Last C
•.blo..•cumin.v.an
D.
Pad 1l.Enter Other$Hnica at Conn/sons Conticutno to Deem.But Not Resulting In Tre Undeayirg Cause Chin In Par,I 29. Was An Autopsy Performed? DYe= eNo
30.Were Autopsy Finding Avaiabl To Complete The Cause Of Deaa7 D Yes D No
31. DA Tobacco Use Connote To Death? 32. If Female: 33. Manner Of Death:
0 w""• 0 A '..at r.•arm,: D P.Pt or xse ...,,w.a..7..nwc..e Natural 0 Homicide 0 Acccent 0 Pending mves:iga5orp vas 0 Probably❑No 0 unw:pwr D,at . e soy...poet mos,to i r•.e• .o.se
0 wq.,e=,..,.,,w..a ar.,t...• 0 Suicide D Ceuta Not Be Determined
34. Date C Injury(MonvJDay,Year) I 35. Tune Of Injury 36. Place C.Injury(E G..Decedent's Home,Contrvcion Sete,Restaurant,Wooded Area) 37. 1.-jury At Wow?
0 Yes 0 No
36.locates Of Injury-Sate 13?a. City Or Town 380. Street B Nmroer 33c. Apt.No. 38d.Lc Ccoe
39.Des:true How Injury Oxureo 111 40. If Tratspeca:inMaury.Soeo`a
Doc.. .er D.--s- Da.,..... Do••iso-:ea
41.Signature,Of Person Cemfying Cause Of Death: 42.CeM1Ser(Check Only One)
AHMAD Z. KARIM , BY ELECTRONIC SIGNATURE 0 Ceral g Pnysldan 0 Coroner , 0 Heath eke.
43,Name,Address And Zr Code Of Person Ce,Sfying Cause Of Death: 44. License Number 45 Date Cer:5.d
AHMAD Z. KARIM ,600 MARY STREET, EVANSVILLE, IN 47747 01061963A 07/14/2014
I46.Additional Funeral Service ProvIdec I 47. 'Alas:
45. Signature of Local Hear:,&ricer: 49 For Registrar Only -Date Rea (MontNDaysYearj
RICKY B YEAGER, VIA ELECTRONIC SIGNATURE JUL 21 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
a(0-1�-i ') - 1100 - 00 . y90 -oa� •
1 .
State Fora 53395 ATTENTION ESTATE:The Social Security:is being requested by Yes stale agency in cyder td pursue respoensibilly. Disclosure is voluntary and there 4 be no penalty for Sisal.
WARNING: ORIGINAL S FROM ORANGE TO YELLOW E?LLOW�ME RUBBED ORIIGINALODOCUM SPECIAL HAS HIDDEN VOID ON FRONT THAT APPEARS VMEN PHOTO COPIED.r ON BACK THAT