Death Certificate - Davis, Eva M_8/6/2014 .+ INDIANA STATE DEPARTMENT OF HEALTH 3497 21
2 't CERTIFICATE OF DEATH
i 1I1
� '' Local No 000162 EDR No 000000397679 State No 034850
1.Decedents Legal Name(First Middle,Last) ta. Maiden Name (If female) 2.Sex 3. Time Of Death 4. Date Of Death(AbmNDayfYear)
EVA M DAVIS MILLER FEMALE 01:30 PM 07/30/2014
Occurred In A Hosp•as. 10a. It Death Occurred Somewhere Other Than A Hospital
0 Hospice Facity 0 Decedent's Home 0 Nurseg Hare& g-term Care Facility
0 Yes 0 No 0 Unknown 0 Inpatent D Emergency Department Outpatient 0 Dead on Arnval fl Other(Speofy)
11.Fatty Name(If Not lnsttmon,Give Steel ad Number)
2960 WEST 50 S
12.City Or Town.Sum.Ana bp Code 13.County Of Dean 14.Memel Suter At Time Of Death
0 Marred fl Maned.But Separated 0 Divorced
PRINCETON, IN,47670 GIBSON 0 Widowed 0 Neer Manied 0 Unknown
15.Sur.wig Spouse's Name 15a.(If Wde)Grve Maiden last Name 16. Decedents usual Occupation 17. Kind Of BusaheWrdtaay
CERTIFIED
LARRY DAVIS ASS STANTNURSING MEDICAL
18.Residence•State 183. County 180. City Or Town
INDIANA GIBSON PRINCETON
1&. Steel And Mincer 18d. Apt No. 15e. Lp Code 1W.Inside City lints?
2960 WEST 50 S 47670 0 Yes ®No
19.Decedent's Educatan 20. Decedent Of NSpasc Orgn 21. Decedents Race
9TH- 12TH GRADE;NO DIPLOMA NOT HISPANIC White
22.Father's Name(First Mende,Last) 23.Meiners Name(First,McKie.Last) 23a.Mothers Maden Last Name
JAMES MILLER JOSEPHINE MILLER HARTLEY
24.Informant's Name 24a.Relationship To Decedent ' 240.Mang Address(Street And Number,City,State.Lp Code)
LARRY DAVIS SPOUSE 2960 WEST 50 S, PRINCETON, IN 47670
25.Place Of Doha-Mon
25a.Method Of Dipositai 250.Pace Of Disposition(Name Of Cemetery.Cremaaey,Other Race) • 25c.locator-City.Town,And State
0 Burial 0 Cremation fl Donation 0 Entombment
0 Removal Fran Sits
fl Other(Specdyp COLUMBIA WHITE CHURCH CEMETERY .PRINCETON, IN
26.Was Canna Contacted? 27. Name And Complete Address Of Funeral Facitty 27a. Funeral Hone License Number:
fl Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
270. Signature Of Indiana Funeral Service Licensee: 27c.License Number(Of licensee
MARK R.WALTER. BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Gain Ot Events -Diseases,(Nunes.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval:Onset
Such As Cardiac Arrest Respiratory Arrest.Or Ventricular Fibrillation Without Showing The Etidogy-Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Addable'Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. METASTATIC ADENOCARCINOMA OF LUNG 6 MONTHS
owata A.•Cvwe G1
Sequentially List Conditions, II Any,Leading To The Cause Listed On B.
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated o...(o...ce..ewe 04
The Events Resulting In Death)Last C.
Pow O.■••G •ew,••On
D.
Part 0.Enter Other -•n. . • • .- - • •im, • ,e But Not Resulting In The Underlying Cause GMn In Part I 29.Was An Autopsy PerfmneT 0 Yes 0 No
30.Were Autopsy Finding Amiable To Complete The Cause Of Death? fl yes fl No
31.Oct Tobacco Use Cantabute To Death? 32. If Female: 33. Manner Of Death:
0 Yes ❑PrKably❑No ❑lMivdxn ®.`°n.ew olio's.r... 0 p ,.4 At Tau a wee, 0 reoene..liet Here.wen 42 nn agar, ®Naval fl Homicide 0 Accident 0 Pehdng Investgation
HerHew,.mee..9,.r u mn r..es deli,•Deer, fltiw.w.end.1 ear.D.Pr vow 0 Suticle 0 Could Not Be Determined
34.Dam Of Injury(MontsDay(Year) 35. Time Of Injury 36. Place Of Injury(E.G..Decedents Home,Casm,cton Site.Restaurant Wooded Area) 37.Injury At Work?
fl yes 0Na
38.loradn Of Injury-Stew 38a. City Or Tam 380. Street&Number 39c. Apt No. 380.LP Cote
39. Descnbe How Injury Occulted 40.If Tre nspaetan lryay.5 try.
flo,...D..... flee..,... LJ ' Do..lxwl
41. Signature. Of Person Cer:tyeg Cause Of Death: 42. Certifier(Check Only One)
MICHAEL LOUIS TITZER .BY ELECTRONIC SIGNATURE ®Certifying Physician fl Coroner fl Heath Officer
43.Name.Address And Zoo Code Of Person Cerayig Cause Of Death: a.License Number 45. Dar Cer„5M
MICHAEL LOUIS TITZER , 3699 EPWORTH ROAD,NEWBURGH, IN 47630 _ , 01041826A 08/05/2014
46.Adbtiana Funeral Service Provider: '' ,'t 47. 'Alas:
4S.Signature of Local Heath OftCee ' s 49. For Registrar Only -Dam Fled(AMWDayfYe.T
BRUCE BRINK JR.VIA ELECTRONIC SIGNATURE AUG 06 2014
AMENDMENT TO CERTIFICATE OF DEAT,:(ENTRY OR ORIGINAL)
d -ll -is ! 00- oCO 1S79Q- earl 'l
State Farm 53395•ATTENTION ESTATE:The Social Security x Ls being requested by this state agency in order to pursue responsibity. Disclosure is voluntary and there will be no penalty for refusal.
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