Death Certificate - Hale, Emma Faye_8/20/2014 - ), 1 -1 1 1 ' 11 1 1 " 1. 1 .1 .1 . , l 1 - O•
.��°`"4, INDIAWASYATEtEPARTMENTOFN • 1078683
i `'t CERTIFICATE OF DEATH
Is' 't.
�` 7 Local No 000117 EDR No 000000388585 State No 025280
1.Decedent's Legal Name(First.Middle,Last) 1a.Maiden Name(If female) 2.Sea 3. Time Of Death 4. Date Of Death(MOnttvDayfYear)
EMMA FAYE HALE FARRAR FEMALE 10:55 PM 06/04/2014
85 Morris Dan Floors Minutes 07/02/1928 LAWRENCEVILLE, IL
9. Ever in U.S.Armed Forces? 10.11 Death Occurred In A fbsgtal: 10a. If Death Occurred Some t,ere Other Than A Hospital
0 fink .Faddy 0 Decedent's Hone 0 Nurseg Home/Long-term Care Fealty
0 Yes 0 No 0 Unknown 0 lnpaient 0 Emergency Department Outpatient 0 Dead on Anal 0 Other(Spcdy)
11.FahLry Name(If Not Ins.cn.Give Street and number)
10461 WEST STATE ROAD 165
12.City Or Town,Sate.And Lp Code 13.County Of Death 14. Marital Status At Time Of Death
OWENSVILLE, IN,47665 GIBSON 0 Married Married.0 er Married ❑known
0 Widowed ❑New Maned ❑Unknown
15. Slwhng Spouse's Na. 15a. (If WW e)Grve Maiden Last Name 16.Decedent's Usual OCCUpabDo 17. Kind Of Businessllndusby
HOMEMAKER DOMESTIC
18. Residence-Sate tea. County 180.City Or Tom
INDIANA GIBSON OWENSVILLE
18c. Skeet And Number 180. Apt No. 18e. Zip Code let.Inside Cdy LVMs?
10461 WEST STATE STATE ROAD 165 47665 0 Yes 0 No
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Father's Name(First tlSde,Last) 23.Mothers Name(Fast Made.Last) 23a_Moults Madera Last Name
JAMES EARL FARRAR MAUDE IRENE FARRAR WIRTH
24.informant's Name 24a.Relationship To Decedent 24b.Maing Address(Street And NAnber,City,Sate.Lp Code)
DIANA K MEYER DAUGHTER 3423 EAST 600 SOUTH, FORT BRANCH, IN 47648
25.Pace Of Disoostbon
25a.Method 01 Osposlsm 250.Race Of Disposition(Name Of Cemetery.Crematory.Oder Rate) 25c.Locaton-City.Tarn.And State
0 Burial 0 Cremation 0 Dc ation 0 Entombment
0 Removal From State
0 Other(Specify MAUMEE CEMETERY JOHNSON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Fecty 27a. Funeral Hone License Number.
❑Yes 0 No HOLDERS FUNERAL HOME OF GIBSON COUNTY, INC., 319 SOUTH MAIN STREET,
OWENSVILLE, IN 47665 FH89000021
270. Signature Of Indiana Funeral Service Licensee: 27c. License Nutter(Of Lirenseek
RANDALL K DIKE , BY ELECTRONIC SIGNATURE FD01010177
Cause Of Death (See Instructions And Examples) Approximate
28.Pan I.Enter The Gain 01 Even -Dseases.trgunes,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 Etiology.Do Not Abbreviate.Enter Only One Caine On To Death
A Line. Add Addtinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. MELANOMA,STARTED IN EYE 14 YEARS
One ono.C..gw<Nr
Sequentially List Conditions, If Any.Leading Tome Cause Listed On B. METASTATIC DISEASE IN LIVER d.c tOr A.1.Cawl.et.a on
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C.
M 510.U.Capon.04
D.
Part a.Enter Other Sid,cant Gwn'Lnns Conm -to Dealt But Not Resulting In The Underlying g Cause Gmn In Pan 1 29.Was An Autopsy Performed? 0 Yes 0 No
NONE 30.Were Autopsy Finding Available To Complete The Cause Of Death? OYes 0 No
31.Did Tobacco Use Contdtete To Death? 32. If Female: 33. Manner Of Death:
❑Yes ❑Probedy®No Unknown
0,e'n.e,.r over..-r- 0 w.r.e.r r...ao.w 0 NWProp r.N n.wnrwa.i in On.thorn 0 Natural 0 Homicide 0 Accident 0 Penang Investigation
0Ne».w.a.r..w.aDSTx1 ins San Cut D Wean Iw.er.'ewa..n.ea rem 0 Suicide 0 Coda Not Be Detemlned
34. Date Of Injury(Month/Oast/ear) 35. Tme Of Injury 36. Place Of Injury(E.G..Decedent's Home,Caistucaon Site,Restaurant Wooded Area) 37.dory Al Wok?
D Yes O No
38.Location 011ryury-Stare 38a. City Or Town 38b. Street 8 Number 38c. Apt.No. 38d. Lp Code
39.Describe Haw Inury Occurred 40 ls
.If Traportad y.a,Lijl y:
Darr,°..- Drs ..' OD.t.-'
41.Sgnabb,e,Of Person Cenlyvg Cause Of Dean: 42.Certifier(Check Only One)
MICHAEL J.ALLEN, BY ELECTRONIC SIGNATURE 0 Certifying Physician 0 Coroner 0 Heath Olfaer
41 Name,Address And LP(win Of Person Certiying Cause Of Death: 44. License Number 45. Day CMCed
MICHAEL J.ALLEN ,3801 BELLEMEADE AVENUE,SUITE 200-A, EVANSVILLE, IN 47714 01048785A 06/06/2014
46.Ad:ib:nal Funeral Service PmiOer. 47. 'Mai:
7
48. Signature of Local Health OFr c 49. For Registrar Only -Day Filed(Month/DayfYeap
BRUCE BRINK JR.VIA ELECTRONIC SIGNATURE JUN 06 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
State Form 95 IATTENTION ESTATE:The Social Secuny tt isbeing requested by this state agency in order to pursue responsibility. Disclosure is vounary and there MD be no penalty for refusal.
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