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Death Certificate - Johnson, Jaynita_9/24/2014 CERTIFICATE OF DEATH D-T&-W.:.C-7:41tA'r‘.tri,717#177\'7',a7709-1(Wer-----47- ... . .. .._ _ ..... _.... . ..... : ,.9y,>-4,7.`”-i,',W,;.,:,;.;;.;.,I: : tr-;,:;.,,,'-i6.; - • 113101ANn...••: :, :is, ......:.7'.. ! . .1. :::," ;IL_ ..,. cc. ,2,1.-,.",; • i.--::-.' : :-..:7.:.:-.5"::.'1.-:::7--1 ..... ll-Y • "I'-i- -c r• ' t- i - i z : `--QCERTIFICATE0KbEATI4' r•-'1 :: z 4 z ,- 1‘, t . :•t-±• , k: -.. „--- . :..-: , = ::, -,.-..-,:z--- t,:-,:-.% 4: ;..,,,;-: ,--- ; .', v; .5 t• .:: = i , •:_%r:i.... ..A ;:- ',.. ' : . :3-' " -/- ' .---2'' :',.,: . -2, I i ;.--- ' .'"-' -..--`<i__ 1"-LeicilNo.000045' \‘' i -,-EDR*0•000000372851\-:, ,-, -,:iStatetio 009830k... „- : Deti ," 4. Data Of Dean:(Month/Daylyear,). , • t,Decedent's Legs/Narne(first.Mialle.Las1)...-' 2-.-..'' ;:i.{ ":•;36,-malcierlNarna.et 1",9316),,s'7 , .'s'iC.' '2'$7%' i ‘' ■aVrine Cit•• '• -21: 7..%:- -.‘,: r',. "'"x.\ --' - '" ,. .: ,. / --',. 'tV ''''k, rtti e.- c e'. - z !-- -': ,•." e- ( 4 - / •' ,./.. ..‘,.; '-; jAYNITA jOHNSOW :7 (‘77-, ',7: 7t z- i:1 ..:'---.. ",-, SMITH'f'-"--- %‘.. <.. :3 Si .....-"• FEMALE. - 05:15 PM 2,7 .-..-:: 6-r-703/02/2014 .'''i' 71 F = Mo;gin '. tk; :Dan '''. : Han''-', 't . lfthias s.•-• :' 1 •.. ' :EVANSVILLE, IN .. ,. ., , , ., „.,. • 9. Ever in U.S.Armes Forced?. 10.If Death°cartes In A Hosptat ... ........_''•--:,....,,, :z.t.;;•.... !:P 1:, ,; '.- , .. - ,., . ..-..; ...b.-, ''''...:,-*:'',., 0 Hospice Fizity EIDeeedenei Hand 0 triursirc HFrnellen9-Wm.,,eme fa0"527.' 0 Yes 0 No 0 Unk.no:n 0 Inpatient 0,Emergency Oeoartnent'Outhedent 0 Dead on Arrival 'abthei(SPOodY) i '''' '' 7 ' •• ' , . ' - ' ' '. II,Fealty Name (II Not Insetution.Ghee Street end Number) '' ' • . ' . ' 603 EAST SINCLAIR :12:City Or Tm.n;Seam,And Zip Code. ; • Al:Comity Of Death ' , 14:Manta Status At Tine Of Death . , .-- • • .. .." • 0 Mddrtied 0 M'arned.art'seThd 0 Di‘vamed . . . , . .. . 'f FORTBRANCH,-IN,47648 7 . . , .z,, 7.-.: :7,;_ , GIBSON -1,:.,. 7/-- 0 wdosT5, a Nevery.arnea,L0 Unknown IS&renting Spouses Name 15a (I:Atfe)Give Maiden last name .. ,.. ,16..Decederas Usual Occupaton • 17. 14id Of Business/II-dusty,- ' , ALUMINIUM: - • .i. 1 MARVIN:JOHNSON ' .., ', 7%. ; 7; : - . 1 : MECHANICAL SUPERVISOR FABRICATION i 7 lea ounty C . - .- .- . . • -: ., . . .. - , ... ••. . ,.. .. _- • INDIANA •. '7 GIBSON --., 1Ffc. Street Aril Number lea Apt No. 1Se. Zit.Code RP Inside City Limes?. ' 603EAST SINCLAIR 1 . . . . 0 Yes.0 No 47648-, ' . : • , :19. Decedents EducatOn... „ „ 20. Decedent 01 Hispanic Ongin . j,„,. • . '21: Decedents ce: ' HIGH7SCHOOL GRADUATE.OR GED - , .. „, .. ... > . . -•. .. • . 22.Father's Name(First MiOde.Last) . ; f,' • 23/Mothers Name(First Maidle.Lasd 23a.Mothers Maiden Last Name.. , •, : 1 RALPH SMITH i GLADYS?SMITH . . . • MCHENRY • • -- . - 24 Informant's Name .24a,Retraons/tip To Decedent ,....., 24b.Malmo Adorns(Street And Nuffidef.City,State.Dio Code) - .. ?I MARVIN JOHNSON 1 - . , HUSBAND . 't'', :- - --: 603'EASTiSINCLAIR,-FORT-BRANCH, IN 47648 . .• - ..... . . • 7 . . 4 41 257.131ace a oispaitia; :: --'7'-` ' - . 25a.Method Of Discos:don 255.Place Of Disposagn(Name Of Cemetery,Cramathry.Other Place)f 25c.Locator,-City.Tann,And State - . . . 0 atrial 0 Creme-don 0 Donation Erccrnoment ' " ' , .' . . ' :0 Removal From Stet , . , .„- ....,...• / . , . - ....,-' - • • 0 Other(Specify): •• . - SECEDER-MAXWELL CEMETERY ", . ..: FLATROCK, IL • •. . - . . .` 26 Was Coroner Contacted? - 0 Yes 0 NO 27. Name And Complete Address Of Funeral Fecihty. w- - -. • '1 ;- :. -.. -,, - :.• . ' ,27ar Rome Horne License Number. FREDRICK&SON FUNERAL HOME INC. 7313 CHURCH:STREET,NINCENNES,!IN 47591'. J FH83006944 27b.Signs-axe Of Indana Funeral Service Licensee: , . , 27c,License Number(Of Licensee): JAMES DOUGLAS GOODVVINE, BY ELECTRONIC SIGNATURE t....../ ,, :, --- .' -- '., - FD09100022 . . - . . .'5 .. „ ,-Cause Of Death.(See Irnmuctkths And Elamples)• -C. • -213.Patti Enter The Chan Of Eventi •Diseases.Injuries.Or Complicationa•-That iiactly CaZt‘ied The ElealTh.Do Not Enter Tertninal Events , .. tritervalf Onie-t " Such As Cardtac Arrest.Respiratory Arrest;Or Vent's:Oar Fits-illation Mina Showing The Etiology..Do Not Abbreytatef Bier Onty.One Cause On A Lem. Add Additinal Lines If Necessary. : ''.'d • ` 1 • ImMediate Cause(Final Disease On Conddion Resifting eath) A_ RESPIRATORY ARREST-SECONDARY TO METASTATIC BREAST CANCER ' . UNKNOWN , . . . . . ' . -_ . . , , 7,, .Sequentially List Gotha:ions, B Any.Leading To The Cause List ed On a -'' '''" - -' - - . . - „ ..., . . Line A Enter The Underlying Cause(Disease Or Injury That Initiated . . . • .: The Events Resutaig In Death)Last C. . .. ..,... Cum Iv Or..A Camps'.06 . . . • . D. • : 1 5 I c f. . , = ,' . ‘. ..'" , . . , ' • , • , .. 'pat II.Enter Other Sp But Not Restierg In The Underlying Cause Givin In Part I .,.: 29.Was An Autopsy Performed? . 0 Yes 0 No .1 1 A : ,tf HYPERTENSION,DIABETES MELLITUS TYPE 2.ATRIA:FIBRILLATION/ACID REFLU'i DISEASE.CORONARY.....r. 30.,Were A ybdpsy Riding Available To Compete The Cause Of Death? ,-; -• ..., ARTERY DISEASE.HISTORY OF PERMANENT PACEMAKER HISTORY OF CORONARY ARTERY BYPASS GRAFT 7 / ,- -0 Yes'LI No 7'", 31.De]Tcoasoo Use Corrthtue To Dethh? 32. If Female: ( . , . .. 1. . : • , • „33.f Manner Of Dern. ' 0 m..t•mgrarethe.,P..'ear 0-,,nranir...:40-1, 0!,.!,`rorin.as i‘ten.n Atm.:(my:orame ' 0 Nedra]0 Homicide i 0 Accident OP. Inveseg,dri . ' 0 Yes 0 Pricbabry 0 No,0 Unknown 1:1 Nal Trite.ELI PP .%0 Don T.I roar eabviL;t71 o;-..Z..-77g p;,.....14,..r.........: .:.-' 0 suicide 0 caid Nal.ga Determin- ec : f. • : .34, Date Of Inpry(Mom:May/Year) 35.Tine Of Injury .: 36.-Place Of easy(EG.,Decedents Home.CalStael Site.Restaurant.Wooded Area).., ,37.-Injury At Work? . . * ''' ' :''. , , . . . „ 38. Lccanon Of Inatry‘Stew , 38.a. Dry Or Town - . ,. 38to'Eatet.S Numbe-- - -- - i 38c Apt.No. „Sad Zip COO& :5 . . f 7 ' • • 'i . , . .." 39.,EleiCnte Mow Waxy OCCurred • ' AO. If Trarisprabon Inpay. wier.fy . • . 0 c.,...,,,,,..... 0.-..., Lfr......-pc..cse.4) "! • , .... „ ... 41.Signature,.Ot PersOn Cellayvig Cause Of Death: . 6 , - 42. certifier (Check Orgy One) . . • . .' 't QUENTIN BRENT-EMERSON , BY ELECTRONIC.SIGNATUgE: .-: 7‘7‘,,71. I;:, --. ; ..c"--- '70 DertfRIV PhYbcfan ' 0 Carona' .`0 Herm' Oes-.er • . '. 43. Name Assess And Zip Code 01 Person Cercfying Cause Of Death: 44. License Number 45. Data Ceitsed • • . . , ..: QUENTIN BRENT,EMERSON-,7861'S. PROFESSIONAL DRIVE,,FORLBRANCH--,z1N,47648r : 01027038A' ' 7 ' . • 03/04/2014.47. 'Akat ..„.. „.. . .,. ,...- GOODVVINE FUNERALHOME- „.\: - , ,. ,. BRUCE SINK JR:,--VIA ELECTRONIC SIGNATURE =t.. t ',...( ..' 1:„ ,."-... J J1 j i .: .- ::. : ,.: -: :. t',NAAR 052014 -.. ; i ,.: - • • .: , - • " • , - - - - • • -AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) ":: 'f; % ' rt•-•.- '1 ": !,': f='•'"', ": T. :, . • .: --'''',t -... t. :>''' •'"•••-: '''. r''' tr.,,,f--. '''...: •-'2 .••-•--„ , .. ., :, --- . .:rf- r---... ''•= C. 0 '= .== '", = 1= .;:. -'.. c i : :::-= : -: :.: :.; •1 , , t< -.: .; ., ., t. c: -; : --, ...,.17.:".. . . .:: .Z ; ..;. .•.- : i 'It. ; ....-: l'S;.;.L.,tit.; r r '.. ; .' _ ., ; ' ;i. _ .$ ,.:: ■ ; :; ! :,7:, .,::' ... • :: . (4- ili .. .: .1 /. : * ,.. • ,. t..,■: . !..",Statetfoi*53395 vAl7ENTION ESTATE:The Social Seounty d IS being requested:Dyithis.stafe agency thatdettopursueresporlsdatity.Otscloaute is volurrary andperrall5ermpettaly ofrresac E., :. ... - .•■-'71 -- •■■••''CiRiGINALz609tAieta}-1A 4 mulmaouDRE6 eAcrEjciFibuit 03/-siciatAliakETsiaigim-i0E-4ATNDiCiE GREAT.SEAL iirfri-ietTokit eliNSakA LitiaA6(71:1Ard. ,.. ._-.';71,41A tt N I N u ... RN FROM•RANGE.T•YELLOWWHEN RUBBED:ORIGINALDOCUMENT HAS HIDDEN VOID e N FRONT1THATAPPEARS WHEN.PHOTO COPIEDKY::I f: °'•.:.--‘. .11`. .5S.C.-TIJCV.'CLAFPal .;E-V:C".1.P.321 .,t(--0: 1 STATE OF INDIANA 'fc=0"'"Srii‘-'"14-' =”.Ze..iee‘t.fa:San:nliE-'9'W‘'S *,-...._;-- _.:-.4...i7.--..•_-_,...k-A,....-..-LIC.13.-,-;:__:..-.-A--17.---..t- .-:-..--1/4:-:.