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Death Certificate - Gibson, Janice D_11/6/2014 4 ;°,'.I-• INDIANA STATE DEPARTMENT OF HEALTH 953174 I:t ij, CERTIFICATE OF DEATH - RESUBMIT Local No 001117 EDR No 000000326936 ' State No 026227 1 Decedent's Legal Name (First MidCie.Last) la Maiden Name (It fema'e) 2.Sex 3 Time Ol Deem 4 Date Of Death(MorCNDayttear) JANICE DIANE GIBSON DAWSON FEMALE i 09:50 AM 06/03/2013 69 Months _ I Days I Hods I Minutes 01/27/1944 COLUMBUS, IN 5 Ever in U S Armed Farces? 19 I:Death Occurred In A Hosptal 10a If Death Octanes]Somewhere Other Than A Hospital ❑Yes 0 NO ❑UnNnpwn 0 Inpatient ❑Emergency Debanmen:Oupabent e nospica Facia), ❑DeQcerc's home ❑Nursing Horne/Long-term Care Faotry ❑Dead m Arrival L7 Omer(Specify) It. Facet),Name(II Not Insttetas One Seem am Number) VNA CHARLIER HOSPICE CENTER 12. City Or Town.State And Zip Code 13. County Of Death 14.Manta Status At Tee OI Death 0 Married❑Marred,But Separated ❑Divorced EVANSVILLE. IN,47714 VANDERBURGH 0 we...ea ❑Never Manned ❑Unknown 15 Surzinng Spouses Name 15: t)1 V.11e(Give Maiden Last Name 16. Decedents Usual Occupauon 17. Kind Of Business4Mus'ry ROBERT GIBSON JR SECRETARY SCHOOL II Resdence-Sate lEa County 15o City Or Town INDIANA GIBSON PRINCETON 15c. Street And Number 1Ed. Apt.No 16e. Zip Cone 13I. Inside City Limits? 214 NORTH 4TH AVENUE 47670 0 Yes ❑No 19. Decedents Education 120 Decadent Or nisr.ant Origin 21. Decedents Race HIGH SCHOOL GRADUATE OR GED COMPLETED NOT HISPANIC White 22.Fathers Name(First Middle.Last) 23 Mothers Name(First Middle,Last) 23a.Mothers Maiden Last Name ARTHUR DAWSON ELLEN DAWSON AMY 24 Interment's Name 24a Relatwnssvp To Decedent 240 Mating Address(Street And Number,City,State.Zip Code) ROBERT GIBSON JR HUSBAND 214 NORTH 4TH AVENUE. PRINCETON, IN 47670 25.Place CI Disposition 75a Monad Of Cespov.on 25b Race Of Dispdsimn(Name Of Cemetery.Crematory.Other Race) 25c.Locabm-Ccy,Town.And State • l Burial ❑Crena'son ❑Donation D Entombment ❑Removal From State ID Cme• (Specie ST JOSEPH CATHOLIC CEMETERY PRINCETON, IN 26 Was Come COnlaaedT 27 Name And Complete Address Ut Funeral F ataxy 27a. Funeral Home License Number: ❑Yes 0 No COL VIN FUNERAL HOME INC,425 N MAIN ST.. PRINCETON, IN 47670 FH83005671 270 Sgratie OI isoon Ebert!Service Licensee 27s. license Number(CI Licensee): JOHN W WELLS , BY ELECTRONIC SIGNATURE _ FD01009940 Cause OI Death (See Instructions And Examples) Apprpumate 26 Pan I Enter The Chao 01 Events .Diseases,Injures,OF Complications-That Directly Caused Tne Dean.Do Not Enter Terminal Events . Irkervat Onset Such As Cardiac Arrest.Respiratory Arrest.Or Ventricular Feordlabm Wthout Shoving Inc Etiology Do Not Abbreviate.Enter ONy One Cause On To Death A Line Ace Acclaim!lines If Necessary Immediate Cause(Final Disease Or Condition Res ling In Death) A GASTRIC CARCINOMA 5 MONTHS d..to ld•••ca..a.,ra on Sequentially List Conditions If Any,Leading TO The Cause Listed On B Line A Enter Tne lindert)irg Cause(Disease Or Injury Trial Initiated a.mn°..ac...w...m The Events Resulting In Death)Last C Dan to 4•c............00- D. Pat II Enter Other 5 jsl,Cdnt Cad..whs Contributing to Demos Burl No:Res:ksn9 In Tne underlying Cause Ginn In Part I 29. Was An Autopsy Performed? 0 Yes 0 No NONE 30.Were Autopsy Fining Available ToCompete The Cause IX Death? ,-. ❑Yes ❑NO 31 Dd%cacao Use Con:noise.i's Chum' 1211 Female 33. Mama Of Death'. 0 w.cyeun',an'a..ai 0 R.TM.t fr.00n. pa.T.r t5a .pvrw.n.2 M1r.a one, ®Natural C Hor.Wae ❑Acoder6 ❑Pendeg Investigation D Yes ❑Probably O No 0 tnrnown 0 h n.awe 4., ,.-,..is nn it r rut roc.eta. ❑u.ra.. m.ea.rat ❑Suede 0 Cold Not Be De:emurzd 34 Date Of'Muni(MmuvDatfl ear) 35 Time Or merry 36 Place Cl hyuy(E G.Decedents Home.Constacton Site.Resdaant Weeded Area) 37. Irytry At Wo1.7 ❑Yes ❑No 36 location CD iryury.State 35a City Or Town 36b Street 3 Number 3EC API No. 36d. Zia Code I 39 Describe More blurs Occme^_ I:1 It Transpa(Je.Iayay�S'er�ry QPn.nq.,av Qhrgn U..aw.n Q'AV•rS.u,l 41. Signature,Ot Person Cen.tiing Cause Of Death 42 Center(Cnecl.Only One/ PATRICK C. FLAMION. BY ELECTRONIC SIGNATURE _ ©Cerying Physician 0 Coroner .❑Heath OScer 43 Name.AOaess And Zip Coda Cl Person Cer yang Cause 0:Death 44. License Number 45 Date Cerv5ed PATRICK C. FLAMION . 801 ST. MARYS DRIVE# 110 EAST, EVANSVILLE, IN 47714 01027520A 06/04/2013 46 Additional Funeral Service Ronde• 47. takes: 45 Signature of Local Health O:lcer 49. For Registrar Only -Date Filed (Main/Day/Year): RAYMOND W. NICHOLSON,JR., VIA ELECTRONIC SIGNATURE JUN 05 2013 AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) 49:06050V13 I-...liddte:DIANA 'p State FO Ills 53395 ATTENTION ESTATE The Social Secunty Cis Deng requested by tries state agency in order to pursue responsoitty. Disclosure is voluntary and mere will De no penalty for refusal. f.c IVRA-20 '• • ?..ti-‘. f (7/05) .