Death Certificate - Black, Sadie_5/8/2013 '^r,{1`\l INUTANAbIAItUtrAKIMtnIyrntHE.In - UJJ'-;11 (ft CERTIFICATE OF DEATH ' Local No 000166 EDR No 000000278960 State No 040033 1.Decedents Legal Name(First.Middle.Last) ta, Maker.Name(if female) 2.Sex 3. Time Of Death 4. Date Of Death(MOrCNDayfear) SADIE M BLACK ATKINSON FEMALE 08:30 AM 09109/2012 10.If Dears Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital 0 Hospice Faulty IH DeaJents Home 0 Nursing HaneionFlem Care Faulty 0 Yes 0 No 0 Unknown 0 Inpatient Q Emergency Department Ott atent 0 Dead on Arrival Q Omer(Speofy) 11.Faulty Name (If Not Inottuton,Give Street and Number) 130 S.GIBSON ST. 12.City Or Town.State.And Zip Code 13. County Ol Death 14.Manta)Status At T.e Of Dear 0 Named 0 Hamad.But Separated 0 Divorced OAKLAND CITY, IN,47660 GIBSON 0 VAdowed Q Never Marred 0 Unknown 15.Semmttg Spouse's Name 15a.(If Wfe)Grve Maiden.Last Name 16. Decedents Usual Occur-aeon 17.Kind Of 2usciess&,dusVY RETIRED SECRETARY ELEMETARY SCHOOL 18.Residence-State 18a,,County isa. City Or Town INDIANA GIBSON OAKLAND CITY 18c.Street And Number 18d. Apt No. 18e.Zip Code 181. Inside City Limits? 130 S.GIBSON ST. 47660 0 Yes 0 No 19.Decedents Educatcn 20. Decedent Of Hispanic Ongn 21.Decedents Race SOME COLLEGE CREDIT,BUT NOT A DEGREE NOT HISPANIC White 22.Fathers Name(First Meddle,Last) 21 Mothers Name(First.Middle.Last) 23a,Moeeds Maiden last Name RALPH ATKINSON FANNIE ATKINSON BARRET- 24.Infmrants Name 24a.Relationship To Decedent 240.Mating Address(Street And Nu.ter.City.State,Zip Code) CATHY WILLIAMS DAUGHTER 10510 E. 125 SOUTH,OAKLAND CITY, IN 47660 25.Place Of Disoosi'uon 25a.Method Of Disposition 25e.Place Of Disp icon(Name Of Cemetery,Crematory,Otter Place) 25c.LocasOn•City.Tom,And State 0 Burial 0 Cremation 0 Donason Q Entombment Q Removal From State Q Geer(Speer/0 MONTGOMERY CEMETERY OAKLAND CITY, IN 26.Was Corona Contacted? 27. Name And Complete Address 01 Funeral Fackty 27a. Funeral Home license Number. 0 Yes ®No LAMB BASHAM MEMORIAL CHAPEL, INC., 226 E.WASHINGTON STREET, OAKLAND CITY, IN 47660 FH83005312 27b.5gnahre Of Indiana Funeral Semite Licensee: 27c.License Number(01 Lkenseek JERRY LEE BASHAM,BY ELECTRONIC SIGNATURE FD01016589 Cause Of Death (See Instructions And Examples) Approximate 28.Part I.Enter TheChain Of Events •Diseases.Injuries.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset Such As Cardiac Arrest Respiratory Arrest Or Ventricular Fibrillation W thout Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death A Line. Add Additinal Lines If Necessary. Immediate Cause(Final Disease Or Cnidlion.Residing In Death) A. RESPIRATORY ARREST 5 MINUTES 0.•e1P.•.r..w.....on Sequentially List Conditions. II My.Leading To The Cause listed On B. FAILURE TO THRIVE 3 MONTHS line A. Enter The Underlying Cause(Disease Or Injury That Initiated p.nfo...re,..e..o OM1 The Events Resulting In Death)Last C onne>w• w...a en D. Pang.Enter Other - -.t ..... • Y.bet •to - But Not Resi:tog In The Undely'ig Cause GMn In Pant 29, Was An Auto1psY Pedprmed? El Yes 0 No POSSIBLE BOWEL OBSTRUCTION 30. Were Autopsy Finding Avaaaole To Complete The Cause Of Death? Q Yes ❑No 31.Did TOOacoo Use Commute To Death? 32. If Female: 33. Manner Of Deem: ❑Yes ❑Probably®No ❑UnMwvn 0 nn P^Pw saw P.cv.., 0 ewe.v..oe'.or own 0 urn e-ww B fir we •zO.w down 0 Naera 0 Homicide 0 Accident 0 Pend c Investgason Q wmw.v,wa Ouln.a.N U D.r•le m a.e.o... Q w.,e•r Pne..awa.,n.Pie r... 0 Suicide 0 Could Not Be Determined 34.Date Of Injury(Men:YDayrYear) 35.Time Of Injury 36. Place Otf Injury(E.G.,Decedent's Home,Cmstructdn Site,Restaurant Wooded Area) 37.Injury At Work? Q yes 0 No 38.locason Of Injury-State 38a.City Or Turn 380. Street b Number 38c. Apt No. 380. Zip Code 39.Detente How Iryury Occurred 40. It Transpa total Inur5 ry. Qorv.,gv.n 0'u -0 oe.(Ier/r1 41.Signature,Of Person Certfying Cause Of Death: 42.Ceder(Check Only One) MICHELLE L.SNYDER,BY ELECTRONIC SIGNATURE 0 Cerfyirg Physician Q Coroner 0 Heath G6cer 43. Name.Address And Z4 Cede Of Person Catryt 9 Cause Of Death: 44. License Number 45. Date Ceruted MICHELLE L.SNYDER . 1808 SHERMAN DRIVE, PRINCETON, IN 47670 02001984A 09/11/2012 46.Add.acinal Funeral Service Proider: 47. 'Alas: 48.Signature of Local Health Olken 49. For Registrar Only -Date Feed(MOntJDayffeark BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE SEP 12 2012 AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) ■ '•1a State Form 53395 ATTENTION ESTATE:The Social Seventy a is being requested by this state agency in order to pursue responsibeity. Disclosure is voluntary end there will be no penalty for refusal. se' GljJ• NRA-20 -'v, f• (7/05)