Death Certificate - Odom, Paul E_10/10/2014 .
�, INDIANA STATE DEP 'TMENT.O. F;HEALTH:
Yt f CERTIFICATEOF DEATH t s s
Jr LoGe ' "000207 EDR No 000000408518' State. 044914 :
I,Decedent a a LLyal Nam.(Fuck Middt ,La1' to Maidenflame of female) 2 Sea,., 3.Tame Of Death a Data Of Dear(MafNDay ear) -
PAUL EDWARD ODOM" ' `MALE 08:54PM Vii' 10/05!2014
Hospital
❑Hospice Fauily ®Deiedenrf Home ❑Nursing Homef_mpterm Care Faday
❑Yes 0 No ❑Unknown ❑Inpaaerr❑Emergency Department Outpatient ❑Dead on Anval ❑'Other(Sp eCify)'
11.Faddy Name Of Not Insetieon,Give Street and Number)
5750 SOUTH 850 WEST
12.City Or Town Coolly State,And Zip Code 13Coolly OI Death 14. Marta)Stays At Time 0:Death
0 Named 0 Marred,But Separated ❑Dirorad
OWENSVILLE, IN,47665 GIBSON ❑)Meowed ❑Never Mamed 0 unknown
15 Stealing Spouse's Name 15a. Of Nife)Grve Maiden Last Name 18. Decedents Usual Occupation 17. Kind Of Businesvindustry
KATHY JO ODOM HOLDER BOILERMAKER BOILERMAKER
15 Residence-State 15a County teD. City Or Town •
INDIANA GIBBON OWENSVILLE
:4 Street Aid Number tad. Apt No. 15e. Zip Code 1af.Inside Coy Lints?
5750 SOUTH 850 ROAD WEST 47665 0 Yes 0 No
19.Decedents Eduction 20. Decedent Of Htspa en
ac Qqn 21, Decedents Race
-
HIGH SCHOOL GRADUATE OR GED
- COMPLETED NOT HISPANIC White
22.Fathers Name(First Middle.Last) 23.M Wars Name(First,Miele,Last) 23a.Mothers Maiden last Name
PAUL ANDREW ODOM HELEN MARIE ODOM HOEFLING
24 Inasrmarts Name 24a Retatinstip To Decedent 24b.Mating Address (Street And Number,City,State,Zip Code)
KATHY JO ODOM WIFE 5750 SOUTH 850 ROAD WEST,OWENSVILLE, IN 47665
25.Place Or Disposuuon
25a.Meted Of Diiposrdm 25b.Race Of Disposition(Name Of Cemetery,Crematory.Other Race) 25c Localat-City,Town,And State
0 Bunal ❑Cremation ❑Donabon❑Entombment
❑Removal Fran State
❑Other(Specify): HOLY CROSS CEMETERY FORT BRANCH, IN
25.Was Coroner Craaxed? 27. Name And Complete Address Of Fungal Facial - 27a. Funeral Hare License Nunur.
❑Yes ®No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
27b. Signature Of Indiana Funeral Service licensee:
27c.License Number(Of Licensee):
ANDREA LYNN VINCENT, BY ELECTRONIC SIGNATURE FD21400005
Cause Of Death (See Instructions And Examples) Approximate
23.Part I.Enter The Chan Of Events -Diseases.Ir-vies,Or Complications-That Diary Caused The Death.Do Not Enter Terminal Events Interval- Onset
Such As Cardiac Arrest,Respramry Arrest,Or Ventnifar Fibraation Without Showing The Etiology-Do Not Abbreviate.Enter Only One Caere On To Death
A Line. Add Adderal Lines I Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A METASTATIC NON-SMALL CELL LUNG CANCER 4 MONTHS
Dam to A.A Gamma o4'
Sequentially List Cotdtuons, If Any,Leading To The Cause Listed On B.
. Line A. Enter The Underlying Cause(Disease Or Irytry Tnat Inflated a.m la..A u:..e.�m
The Events Resulting ln Death)last C.
a.mio24•cer..am:w a.
D
Pat II.Enter Other Simi` C C but' Death But Not Resulag In The Underlying Cause Givn In Pan I 29.Was An Autopsy Performed? 0 Yes 0 No
30.Were Autopsy Finding Available To Complete The Cause Of Death? 0 Yes ❑No
31.Did TWacm Use Cambute To Dean? 32. If Fe._,ye_ 33.Mama Of Death: '
0 Yes ❑ PrWaUly❑No ❑Unknown
0 n.my nvener New ❑n.aw Ai rev.a awn ❑rut w.a.n.en neaw.winco•m acne ®Natural❑Homicide ❑Accident ❑Pending'mestga6m
0'm'n.a.tievt amens aoat ra n,..'e.n.uw fin.-+:�an.s+w v.<n The nerve 0Suiade0 Cold Hoe Be Determined
34. Date Of Injury a(n-State 3liar. City Or Town Set.•.:team b Number Sac. Apt No. 383. Zip Code
39. Desabe Now Irryry Occurred I 40. II Transpata*n Lryvy.Speoy.
Gp:.e,ten 0. LJP.d...a pee Spewy)
41. Signature, Of Person Ceettyng Cause Of Death 42.Center(Check ONy One)
EDWARD PATRICK FOX, BY ELECTRONIC SIGNATURE 0 Cerafyirg Physician ❑Coroner ❑Heath OtSar
-
43 None.Address And ZA Code Of Person Cest.A'yig Case Of Death: __- 44. License Number 45. Dais Cert_`.ed
EDWARD PATRICK FOX ,3699 EPWORTH ROAD, NEWBURGH, IN 47630 t 01038620A 10/07/2014
46.Add:aanal Funeral Service Provider.. .•� 4I. 'Aides: .
. . . .. . ♦. . .
42.Sgrsvre of Loa!Heath Ofbur.' -49. Fo r Registrar Only Date Feed(MmaNDayrrea}
��: BRUCE BRINKJR,.VIAELECTRONICSIGNATURE - - - 1.:OCT 082014 . .. :
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY;ORORIGINAL) ) _ ..
o , n-1\ Ioo Uw,-;. ilirl.oa� f a
Stile Font 53335 ATTENTION ESTATE'The Social.Secun'y P is being requested by this State agetry in order t0 pursuelasporuaitY Distlosure is volun anaril there wi8.be 10 peneay./gretusel!
WARNING ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHIIE SECURITYPAPER AND THE GREAT SPAL OF THE STATE QF INDIANA ON BACK THAT'" '
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