Death Certificate - Davis, Robert W_4/11/2014 THISISVIDERC1ALIELY,tOERE$ORD!OEDEATHEORIGINALfCOPY ON'FIECATIINDIANAISTATE'DEPARTMEN 19111 EALTHIN
4 INDIAITA S A E I P•12TATIENT O •tTH 10 9 2 7 8 2
k-7 i; CERTIFICATE OF DEATH
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\`e eats Local Fe .L s) EDR No 000000349359 State Time 048520
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1.Decedents Legal Name IFeA LLaae,Last) la.Maiden Name Of female) 2.ice. 3.Tvre Ol Death •4.Date 010eaLN(I.brclAaYA'ear)
ROBERT W DAVIS
MALE 04:30 PM 101202013
10.It Dear Oconee In A Hosp44: Ica.U Death Occurred Somewhere Other Than A Mosalal
0 Hospice Fac y ®Decedents Home 0 Nursing HCne&0n9tmI Care Fealty
D Yes 0 N D Un1.nWn 0 Inpatient 0 Emagency Department()potent 0 Deal on Arrival 0 Other(Seedy)
Is.Fang),Name(If Not 51055os.Give Street and Ferber)
3371 WEST MARY ROBERTS DRIVE . 13 eanymDeam II.MaeaslauaTmeaDeap
12.Cey Cr Teen Sate.AM Zv Cale
0 Mated 0 Memel Out Separated 0 Divorced
PRINCETON, IN,47670 GIBSON 0 Wocv.ed D Never Metal 011k1eek
15.Surviving Spouse's Nano 15a.(If W8e)Gi a Maiden Lest Name 16.Desdents Usual Occupation 12.Kea Of eabesLUasay
ANITA L DAVIS _ARCHER COAL MINER COAL MINE
19.Residence-State lea.County lea City OrTPM
INDIANA GIBSON PRINCETON
tee Street Ano Number led. Apt.No. 18e.lip Code 181.LSide City Lints?
0 Yes 0 No
3371 VEST MARY ROBERTS DRIVE 47670
19 Decedents Educates 20.Decedent 01 Hdperuc Onys 21.Decedents Race
8TH GRADE OR LESS NOT HISPANIC White
23.Manes i(Fat,ear Mbae.Last) 23a.Abthers Haden Last Name
22.Fathers Name(Foss. Last(
UNKNOWN PEARL J JONES DAVIS
24.L br-anrs Name gas Reasonsep To Decedent 245.Maine Address(Street Anc Number.Coy.State.Zip Code)
ANITA J DAVIS WIFE 3371 WEST MARY ROBERTS DRIVE, PRINCETON. IN 47670
25.Place Of Deposton
25a.Method Of Drsposiean 254 Race Of Pspositen(Name Of Cemetery,Crematory.Other Race) 25c.Location•Cry.Town.And Sate
0 Bus!0 Creation 0 Denton 0 Entombment
0 Removal From Sae
0 Deer(Speayr COLUMBIA WHITE CHURCH CEMETERY PRINCETON,IN
26.Was Canter Cot-acted? 27.Name And Cmpkte Adbeas Of Funeral Fanny 27a.Funeral Itme License N:mber.
0 Yes El Na COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON,IN 47670 FH83005671
27z.Sg:aarte Of Liana Fungal Smite Licensee: 27:.Leense Number(Of Lice-seer
!JOHN W WELLS,BY ELECTRONIC SIGNATURE FD01009940
Cause Of Death (See Instructions And Examples) Approximate
25.Pan I.Enter The Clain Of Events -Diseases,twin.Or Canpecalons•That Directly Caused The Death.Do Not Enter Tertanal Events Interval: Onset
Such As Cardiac Mat.Respiratory Arreal,Or Vent-attar F MMI1C l Wthan Shcw'ng The ELdogy.Do Not Mbre.Fae.Enter Orgy One Cause On To Death
A line. Add Addtna,Lines U Necessary.
bnniedlate Cause(Fatal Oseaso Cr Condition Resdtng In Death) A METASTATIC NON-SMALL CELL LUNG CANCER II MONTHS
0.n 91Orry.Gwwoh
Sequentially List Calemons. U My.Leading To The Cause Listed On B-
rr.wro...C.....-s.e00
The EvA.ents Enter The DMn Dean Cause(Disease O<tryuy That Initiated
The Events Resutig In Dean1)1331 C. 0. 0
•r u .a.e.9.of
D.
Pate.Enter Other Scoffcant Content,ConehN4 to Dealt Rut Na Reatrg In The Underlying Cause Gum N Pal l 29.Was M AaoOsYPenamed? 0Yes 0 N
30.Wee Autopsy Fending AvastaAe To Ccom ete Tee Cause 01 Death? D yes 0 No
Ti.Dd Tobacco Use CoMMAe To Derr? 32.If Fem. : 11 Manner Of Death:
0 r.99.99.....4.19. 0 Ann..us..ap.... D Asnno.a e.w...rw.w..s on.mby. 0 Nadal 0 Hmarde 0 Arrdaenl 0 Pevano lreestgaon
Yes ❑Probably❑No ❑Unlmpvn 0 recta-se ion.:,..OD-nt•I Ter a.e.Des 0 fetes•newnvire re eye.... 0 Sddde D Cord Na Se Detented
35.Da e of eery(McnWDeyNear) 35.Time Of IniurY 36. Pace Of injury(E.G.,Decedents Horne.Cmnutun Ste.Raaaatt Wooded Area) 37.Irhxy Al woe?
0 Yes 0 Nc
38.locator ONryry-Sat 38a. Cry Or Town 380. Steel&emitter 38c.Apt No. 38d.Zs;Cede
40.IiTmspma• epvy.5peo.Y
39.DesmM HO.v Wary Occurred Dpw•we.•s 0....v U•°w Do.. B xe
at.Sgnatre.Of Person Caaycg Cause Cl Deaot 42.Center(Check Only Ore)
CHRISTOPHER BRADEN,BY ELECTRONIC SIGNATURE 0 Cemfaag Rysldan 0 Coroner 0 Heart D.-_
43.Name.Address AM Zip Code Of Person CerraTm°Cause Of Dear. 44.License N,stLer 45.Date Cerded
CHRISTOPHER BRADEN ,4055 GATEWAY BLVD. NEWBURGH, IN 47630 02003326A 1023/2013
T.Was:
45. Aedi:vnl Puffers Serves Rakla:
od.5gnavrt diLodal Meat Oda- 69. For Registrar Only-Dab Fled(MonelfDayylearl:
I BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE OCT 24 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
State Form 53395 ATTENTION ESTATE:The Social Securty e ie being requested by this state nanny In order to pursue responsib'uty. Disclosure is voluntary and there wt be no penalty for refusal
IVRA 20
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VOID IFIALTEHED_;_ONIERASED t;;NOT_VACID;ONLESS�.6ERTIFIED RYIHEALTRDEPARTMENT