Death Certificate - Beasley, Howard D_7/18/2013 -;..TNIS:ISAN:NPHC_ULfZOP.T_ f.flfA IDDFD FAAi.1DRIDINALICOPYtON�ATiNDIANASTAT EEPm, .11. IFd1EALTN-1,f...
7- - ` INDIANA STATE DEPARTMENT OF HEALTH 0 2 0 7 0 2
., CERTIFICATE OF DEATH
•1• %Y Local No 000264 EDR No 000000322638 State No 022082 4 -
t Deceerirs Legal Name(Fast IIMe.Last) la.Madera Name(if female) 2.5e. 3.:me 0f Dear. • 4.Date Of Cent(Mans Dayrt ea')
HOWARD DUANE BEASLEY MALE I 04:49 AM 05/08/2013
to.tl Dern OaunM In A noaMa0 10a It Dealt OCUIreo SmneeAtere Omer Than A nasaeal
0 Yes 0 No ❑Unknown 0 Inoasenl 0 Emergency Department ON. 0en1 0 Dead on Arrival 0 Hospice m st m) ❑Decedent's Home ❑Nu:sy rbr A.ag�letn Cam FaWy
❑Omen(5peae/)
It.Facto Name(If Not linkmen.Get sweet and humour) c - a .
DEACONESS GATEWAY
I2.Cory Or Torn.State.AM to Coce 13.Cony Of Dean 14.Manna'Sous At Mme Ol Demm
0 pace 0 mama. m � Diverted
NEWBURGH,IN,47630 WARRICK _ D endowed D Ne"°aemed D un"n"r.
le.Sunewig S•Jmes Name -_ 15a.Vl sWe)C Made..Last Name . 16.Decenenls Usual Osapator. 17.Cat Of BtealeYmmsry
MARY JANE BEASLEY WOOD LABORER FACTORY
IE Rewrite-State tea.Canny 15o.Lay Of Teen
INDIANA GIBSON FRANCISCO I
tec tree AndN:mber too.AµNC. lee.Lo Cade laa Umttoy Lust?
302 5.CENTER ST 47649 0 Yes 0 No
tE Decedecs EO.nos 20.Oececenl Or Noorac&cM 21.Deteeenli Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Earners (First Mme,Last/ 23.sromds Name(Fest Mme.Last) 23a.loi errs Maem Lau Name
HOWARD BEASLEY MABLE BEASLEY I MCKINNEY
34.Murano Name 24a.Retawnsro To UecMCt 249-Mang Acmes,(Sweet d noer.City.State.zm Cate)
MARY JANE BEASLEY WIFE 1 And NU
302 5.CENTER ST,FRANCISCO.IN 47649
29.Place a a:oov,on I
25a Me om CA Rs arson 25m Race Of asNVb:(Name Of Cemetery.Crew aory.Ones Pace) 25c.Loa.-Cry.Tam.M=State
0 arty 0 Cmvson 0 Oona m 0 Ennis ent
❑Removal Fran State
0 Diner(soemyt 10 0 F CEMETERY FRANCISCO, IN
26.Was Come Cwtaeed? 27.Name And Complete Admen Of Funeral Fa Aty 27a.Funeral Irate Lemnos Nt.'tw.
D Yes 0 No LAMB BASHAM MEMORIAL CHAPEL,INC.,226 E.WASHINGTON STREET,OAKLAND CITY,
IN 47660 FH83005312
275.*nacre Of Indiana Funeral Service Licensee 27c.License Nurttt IOf ucensee) - _
JERRY LEE BASHAM ,BY ELECTRONIC SIGNATURE I FD070165B9
Cause Of Death (See Instructions And Eaanpletl Aoprotrnate
25.Pan I.Enter Tree Crean OI Ever^s -Diseases.Uyunes.Or Cameacatms•Trial Directly Caused The Death.Do NIl Enter Temtal Events Internal:Onset
Sum As Cardiac Arrest,Respiratory Met Or Venncvlar Rmlaum W;mut Snoxuy The Eldogy.W Not AOaertate.Enter ONy One Cause On To Dean
A Lne_ ACC MdCUat Wee U Necessary. I
L.Tecate Cause(Final Disease Or Conc;mn Resulting In Death) A. CARDIAC ARREST 4E HOURS
Id..•lo r•ta.....M
Secuensarl Lot COMPOns. C My.Leaden i o The Cause Listed On 8. CARDIO2.4YOPATWY UNKNOWN
Line A- Enter The Underlying Cause(Disease Or Injury Trial rebated onto r.tom......d.
The Events Ramat g In Death)Last C.
D..ID..AL.........d.
D. I _
Part II.Enter OmerSnnfirant Co:Tns CmmW,^R to Dean But Not ReuNg In The Underlyrg Cause Gina N PM I 12E Was An Anatomy Pelwned? D Yea 0 No
MORBID OBESITY 130. Here Autopsy Finding A.a4ave To CoeTOea The Came Of Deaee? D Yes D ND
31.DM icoamd Use Commute To Dean? 22.N Female: I 33.Manner 04 Dean:
❑res ❑Prdoady Bng OM:nnwn 0..o.e..we........ 0e ..T...or_ 0 Mane...piitoomoa sou ao ono o-_.m 0 Navas 0 Hatone 0 Armeea 0 Penang m.esgaDf
0e. a ton.t nor. 0 e ... 0 Sumce 0 Cont Not Be Determined
34.pale Ol U's-p(MnlM3aynerl 35_Tine Of Man 36.Place 01 r¢ury IEG..Deceoenrs Mona.Cmsruoen See.Restaurant,Woofed Neal 37.Iryvy At Was?
. I D yes O No
35.Locason Dl lnury'State 34a.COy Or Ton I 360.5Sen6 Number 3BC.Apt.No. 380,So Caere
30.Des Hoe lryhy Oceuned 401 pia'aoa'a+m lr{ury,5
-�--- De.� I 0ee.rs..d .
AI.Signature,Of Posen CeMyeg Crne Of Death: s,2.Certifier(Cnea0. M)
DAN VARDI.BY ELECTRONIC SIGNATURE 0 Cerawlg Pnyreran D Genera. 01ectaxer
43.Name,Address AM So Coe Of Person Ce uyeg Came Cr Dem: 44.License Nitrite 45.Date Ctt:6M
DAN VARDI ,519 HARRIET STREET. EVANSVILLE. IN 47710 01068705A 05/09/2013
4E Maternal Funeral Senate Pleader: 147.'Akin:
St acre OlLeal Hearn GI:ee. 4 49 For Reglsuer Only -Gate Film pnanuaOayMeaa
RICKY B YEAGER,VIA ELECTRONIC SIGNATURE MAY 09 2013
I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
State Fan:3395 ATTENTION ESTATE:The Social Security e is bung reCtesteo oo Ws mate agency in coder to pursue resoonvaay. Osdosure is vak:nary and there AD Dennis penalty fa'MIMI-
Nf V.-2D
(7/05)
fr-irt 1ffALTE1®DN$WSED-'NOT#IALO]'DNLESSDERNFaiHymaniiDEPF111MENT