Death Certificate - Dayvolt, Clarence E_8/25/2014 THI 11 OFFIgALrC_OP,Y{OF,REGORD OFiOEA_THSORIGINAHICOPY ON EILE!A;INDI: ` ! i I t Y • ' 1 I . g g 6 8 5 8
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i CERTIFICATE OF DEATH •
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",n>- Local No 000018 EDR No 000000303944 . State No 005047
1.Decedent's Legal Name(First.Middle.Last) tat Maiden Name (If female) 2.Sex • 3. Time Of Death 4. Date Of Death(Mbn:^JDaylYedr)
CLARENCE EZRA DAYVOLT MALE 04:10 PM 01/24/2013
76 Months Days • Hors Nunutes 10/15/1936 EVANSVILLE, IN
9. Ever in U.S Armed Forces? 10.It Death Occurred In A Hospital: ` 10a. It Death Occurred Somewhere Other Than A Hospital
0 Hospice Fealty ®Decedents Home 0 Nursing Home/Long-term Care Fadity
0 Yes ❑NO 0 Unknown ❑Inpatient ❑ Emergency Debarment OU9x ens ❑Dead on Arrival Q OTer(Speciy)•
11. Fealty Name(If Not Insda:ton,Give Street and Number)
2019 SOUTH 650 ROAD EAST
12- Cdy Or Town,Sate,And Zip Code 13. County Of Death 14_ Mental Status At Time Of Death
0 Married 0 Marred.But Separated 0 Divorced
FRANCISCO, IN, 47649 GIBSON 0 endowed 0 Never Married 0 Unknown
15. Suntwg Spouse's Name 15a. (If Wit e) ive Maiden Last Name 16. Decedents Usual Occupation 17. Kind Of BusinessAndustry
MARIA DAYVOLT MEULLER WELDER MINING
18. Residence-Sate t8a. County 180.City Or Town
INDIANA GIBSON FRANCISCO
lac.Steal And Number 18d. Apt No. 18e. Ziprrete 18f. Inside City Limas?
2019 SOUTH 650 ROAD EAST 47649 0 Yes 0 No
19.Decedents Education 20. Decedent Of Hispanic Origin 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Father's Name(First Middle.Last) 23.Motnets Name(First,Middle,Last) 23a.Mother's Maiden Last Name
LEMAN DAYVOLT GOLDA WHITACRE DAVIS
24.4:bntants Name 24a.Relationship To Decedent 24b.Maine Address(Street And Number.City.State.Zip Code)
MARIA DAYVOLT WIFE 2019 SOUTH 650 ROAD EAST, FRANCISCO, IN 47649
25.Place Of Disposition
25a.Method Of Disposition 25b.Place Of Dispositon(Name Of Cemetery.Crematory,Other Place) 25c.Locato-City,Town,And Sate
Q Burial 0 Cremation 0 Donaton 0 Entombment
Q Removal From State
Q Omer(Spea!y): EVANSVILLE CREMATORY EVANSVILLE, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Faciity 27a. Funeral Home License Number.
0 Yes 0 No DOYLE FUNERAL HOME, 520 S MAIN ST, PRINCETON, IN 47670 FH10400010
270. Signature Of Indiana Funeral Senice Licensee: 27c.License Number(Of Licensee)
BARRETT W.DOYLE,BY ELECTRONIC SIGNATURE FD29500009
Cause Of Death (See Instructions And Examples) Approximate
26.Pert I.Enter The Chain Of Events -Diseases,Injuries,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 Cause On To Death
A Line. Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. LUNG CANCER WITH BONE METASTASES 9 YEARS
w..lo u..c...........co
Sequentially List Conditions, It Any.Leading To The Cause Listed On B' w..bo A...a•....a on
Line A_ Enter The Underlying Cause(Disease Or Injury That Initiated
Tne Events Resulting In Death)Last C.
w.mlo-AA V..o,.40m
D.
Pan II.Enter Other Sgnx,cant Conditions Cpmnbutnd to Dean But Not Resulting In The Unce'Isg Cause Givin In Pan I 29.Was An Autopsy Performed? Yes 0 No
30. Were Autopsy Find g Asafabe To Complete The Cause Of Death? QYes 0 No
31. Did Tobacoo Use Carnotite To Deane? 32. If Female: 33. Manner Of Dee':
Q w..,rte Y.. 0 P,m-+tint or u44. ❑.w=.•>or.receee w...41 Cm a lit..* 0 Nasiral 0 Homicide 0 Accident 0 Penang Irnestgadon
0 Yes ❑Probably 0 No ❑unknown Q w,,,w.0 9.•r.pm 430..[5„a•B..•o..R Q u..,.-.e=,..,.,,wa.n.P.a
❑Suicide 0 Could No Be Determined
34. Date Of Injury(MonNDayrYear) 35. Mite Of Injury 36. Place Of Injury(E.G..Decedents Home•Ccestucson Site,Restaurant Wooded Area) 37.Injury At Work?
Q Yes 0 No
38.Location Of Injury-Sate 38a.City Or Town 38b. Street Number 38c. Apt.No. 38d. Lc Code
' 39.Describe How Inryry Occurred 40. It Transoonatim Injury,SSacify.
ODs-i's.•v Qa.v.F. LJceeesw Qdelsa errs
41. Sgnamre. Ot person Gerlyi g Cause Of Deem: 42.Cenfter(Check Only One)
MAQBOOL AHMED, BY ELECTRONIC SIGNATURE 0 Cenying Physician 0 Coroner Q Heath O.bcer
43.Name.Address And LP Code Of Rsson CM-tying g Cane Of Death: 44_License Number 45. Data Cent ed
MAQBOOL AHMED ;421 CHESTNUT ST, EVANSVILLE, IN 47713 01054343A 01/3112013
46.Addltoral Funeral Semis Provider. - 47. 'Akan:
48.Sgnathre of Local Hearn Off.cx. 49. For Regiserar Only -Date Filed(MontJDayrteark
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE FEB 01 2013
• AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
acs - 13-1cc- 09-opo, Ho9- 00Y
J• _`fi.d
'�State Form 53395 ATTENTION ESTATE:The Social Secsnty 4 is being requested by this state agency in order to pursue resoonsibttry- Disclosure is voluntary and there will be no penalty for refusal.
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