Death Certificate - Harris, Mollie_8/29/2014 _. n•,e`_v_. � �_,_� _INDIANA STATED P R`f v `-• v - tS ! U L J
_k °/
CERTIFICATE OF DEATH
k
' =-' Local No 000156 EDR No 000000335185 State No 040240
I.Decedents Legal Name(Fest,MOPe.Last) Ia. Maiden Name(If female) 2.Sex 1 Time Of Death 4. Date Of Death(Mont'WaylYear)
MOLLIE KAY HARRIS DOWNEY FEMALE 01:00 AM 07/25/2013
59 Months Days Hours Minutes 04/13/1954 TERRE HAUTE, IN
9- Ever in U.S.Anted Forces? 10.If Death Occurred L A Hospital: Ida. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility 0 Decedent's Home 0 Nursing Home/Long-team Care Facility
0 Yes 0 No 0 Unknown 0 lnpauent 0 Emergency Department Gothatent 0 Dead on Arnval 0 Other(Specify)
11.Fealty Name(If Not Instvton,Give Street and Number)
1222 WEST 1200 SOUTH
12.CM Or Town,Sate.And Zip Code 13. Cony Of Death 14. Mantel Status At Time O'Death
0 Manned 0 Named.But Separated 0 Divorced
HAUBSTADT, IN,47639 GIBSON 0 Wdawed 0 Never Mamec 0 Unknown
15.Surwwg Spouse's Name 15a.(If Wie)Give Maiden last Name 16. Decedents Usual Occupation 17. Kind Of BusinessAnoustry
DONALD HARRIS OFFICE MANAGER MEDICAL
15..Resuence-Sate 1Sa. County 180. City Or Town
INDIANA GIBSON HAUBSTADT
18c.Street And Number 18a. Apt No. 15e. bp Code 15f. Inside city Limas?
1222 WEST 1200 SOUTH 47639 0 Yes 0 No
19. Decedents Educason 20. Decedent Of Hispanic Origin 21. Decedents Race
SOME COLLEGE CREDIT, BUT NOT A
DEGREE NOT HISPANIC White
22.Fathers Name(First 81a11e,Last) 23.Mothers Name(First,Middle.Last) 23a.Mother's Maiden Last Name
LOREN DOWNEY JEWELL ENNEN ARTHUR
24.Informant's Name 24a.Relationstvp To Decedent 240.Mating Address (Street And Number,Cty.State,bp Code)
DONALD HARRIS HUSBAND 1222 WEST 1200 SOUTH, HAUBSTADT, IN 47639
25.Place Of Disposition
25a.Method Of Disposition 25o.Place Of Disposition(Name Of Cemetery.Crematory,Other Place) 25c.Locator-Ciy.Town,And State
0 Burial 0 Cremation 0 Donavan 0 Entombment
0 Removal From State
O Otter(Speedy/ EVANSVILLE CREMATORY EVANSVILLE, IN
26.Wa Carnet Contacted? 27. Name And Corr Pete Address Of Funeral Facility 27a. Funeral Hare License Number.
0 Yes ❑No BROWNING FUNERAL HOME,738 DIAMOND AVENUE, EVANSVILLE, IN 47711 FH10800012
270- Sgnasure Of Ineara Funeral Service Licensee: 27c.License Number(Of Licensee):
BRIAN E.JEWELL, BY ELECTRONIC SIGNATURE FD29700013
Cause Of Death (See Instructions And Examples) Approximate
20.Pan I.Enter The Chain Of Events -Diseases.In odes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Venmtvlat Fio:ilation Without Snowing The Etiology.Do Not Aboreviate.Enter Only One Cause On To Death
A line. Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. POLY PHARMACOLOGIC INTOXICATION HOURS
a...no vu cwvu .von
Sequentially List Conditions, If Any,Leading To The Cause Listed On B.
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated CO o.eto�••�"��
The Events Resulting In Death)Last C.
an o:a..•ca..vw 08
O.
Pat u.Enter Omer iinfcAntCoMNgns COnonbus q to Deem BM Na Raut'utg mine Urldenyig CauS4 v'irn to Pan I 25.Was An Autopsy Performed? o Yes ❑No
MORBID OBESITY,LEFT VENTRICULAR HYPERTROPHY,PULMONARY EDEMA.CHRONIC LYMPHOCYTIC 30.Were Autopsy Findvg Avatable To Complete Tne Cause Of Death?
THYROIDITIS ®Yes 0 No
31.Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
❑Yes ❑Probably❑No 0 Unknom 0_w.,... ..,.env.. 0 Pn;no■.t rat.a Can D`un..ev.r.v.e,.n.v....ry•r.ar.. 0 Nac d e 0 HOmitide ❑Accident ❑Penang L'.vesimavon
0..,r=nn."1&.t•.....a•a NO I.t n.•awe..owe, 0 u......r.....w..`The N.Y0. 0 Suicide 0 COUk Na Be Determined
34.Data Of Injury(MgniNDayfYear) 35. Tate Of Injury 36. Place Of Injury(E.G..Decedents Herne.Ccnsauction Ste,Restaurant Wooded Area) 37.Injury 4l Work?
D Yes O No
38.location Of Injury-Sax 38a.CaY Or Town 380. Street 8 Number 38c. Apt No. 380. Zip Code
39. Deana How lryury Occurred 0.al .cee..OrtaO Iv'LJ ...., Dw..is..art
41.Signature,Of Person Cert./11N Cause Of Death: 142.Cert_5a(Check Only One) LLJJ��°°
BARRETT W. DOYLE, BY ELECTRONIC SIGNATURE 1 0 Cen.fying Physician 0 Coroner 0 Heath O.xer
43. Name,Address And bp Code Of Person CeMying Cause Of Death: 44. License Number 45.Date Cert.Sed
BARRETT W. DOYLE ,520 SOUTH MAIN ST, PRINCETON, IN 47670 08/29/2013
46.AOd.uonal FuneN Service Provider 47. 'Alias'.
48.Signature of Local Health Of6cec [42. For Registrar Only •Date Filed(MOnOLDayireart
BRUCE BRINK JR.VIA ELECTRONIC SIGNATURE I SEP 04 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
aCO -aa-1?.. 30o -Dot .53 to -OR 4
State Forms 53395 ATTENTION ESTATE:The Social Seamy=is being requested by ttus state agency in order to pursue responsio'uty. Disclosure is voluntary and there will be no penalty for refusal.
- ' ' WRA'20
(7105(
..may-. _.. .r 7..yrya..... ...--r ....s..>;.-e._r