Death Certificate - Dollahan, Clara B_4/2/2014 .r°eT%v INDIANA STATE DEPARTMENT OF HEALTH 10 7 8 7 5 E
��q�'`_�', CERTIFICATE OF DEATH
1. Local No 000038 EDR No 000000370879 State No 007934
I.Decedents legal Name(Fit Meade.Last) la.Maiden Name Bt female) 2.Se. 3. Tune GI Death 4. Date Of Death(l. r.NDayll'ear)
CLARA B DOLLAHAN THOMPSON FEMALE 10:50 AM 02/19/2014
10.If Death Occurred In A Hospital: 10a. d Death Occurred Somewnere Other Than A Hospital
0 Hospice Facility 0 Decedents Home 0 Nursing Horne/long-term Care Facility
❑Yes C No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival O Other(Specify)
It Facility Name(If Not InSptaal.Gee Street and Number)
610 POLK ST
12. Cry Or Town.State.And Zip Code 13.County Of Death 14. Mantel Steers At Time Of Death
0 Maned 0 Mamed.But Separated ❑Divorcee
OAKLAND CITY. IN.47660 GIBSON 0 WId wB0 0 NeverA1niGd 0 Unknown
15. Sunman;Spouse's Name Ma.(IIWVe)Give Maiden Last Name 16. Decedents Usual Occucamn 17. Kind Of BUSitessAadusny
JAMES DOLLAHAN HOUSEWIFE HOUSE
18. Residence-State tea. County _o. Cm/Or Town
INDIANA GIBSON OAKLAND CITY
19c. Street And Number 1Bd. Apt No. the. Zip Code ref.Inside City Lints?
®Yes ❑No
610 POLK ST 47660
19.Decedents Educason 20. Decedent Ot Hispanic Ongn 21. Decedents Race
8TH GRADE OR LESS NOT HISPANIC (White
22.Fathers Name(First Made.Last) 23.Moother's Name(First.Mode.Last) 23a.Mother's Maiden Last Name
RUSSELL THOMPSON ZEDITH THOMPSON WALTON
24.Informants Name ' 24a.Peabentrap To Decedent tab.Mtat g Address(Street Ana Number.City,State.LS Code)
JAMES DOLLAHAN HUSBAND 610 POLK ST,OAKLAND CITY, IN 47660
25.Place Of Disposition n
25a.Method Of Dsposmoa 25b.Race Of Disposition(Name Of Cemetery.Crematory.Omer Race) 25c.Location-C,ty,Town.Ana State
El Burial 0 Cremation 0 Donation 0 Entombment
❑Removal From State
0 Other(Speddyk EVANSVILE CREMATORY EVANSVILLE, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Faotty 27a. Funeral Mane license Number
p Yes ®No LAMB BASHAM MEMORIAL CHAPEL, INC., 226 E.WASHINGTON STREET,OAKLAND CITY,
IN 47660 FH83005312
27o. Signature Of theism Funeral Service Licensee: 27c. license Number(0f Licensee):
JERRY LEE BASHAM , BY ELECTRONIC SIGNATURE FD01016589
Cause Of Death (See Instructions And Examples) Approximate
29.Part I.Enter The Chain Of Events -Diseases,Iniunes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest Respiratory Arrest.Or Ven:molar Fmntlation Without Snowing The Etiology-Do Not Abbreviate.Enter Orly One Cause On To Death
A line. Add Additinal lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. CHRONIC OBSTRUCTIVE PULMONARY DISEASE 3 YEARS
oar,.4•dwe.we.vm
Sequentially List Conditions. If Any.Leading To The Cause Listed On . ore eta.s•w..,..e on
line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. da eta...v,..:...tan
D.
Pan IL Enter Oter$4mfipant CONItiagCdntbuer0 to Death But Not Resulting In The Underlying Cause GNn In Part l 29. Was An Autopsy Performed? O Yes 0 No
30.Were Autopsy Finding Available To Comdre The Cause Of Death? O Yes ID No
31.Did TObarm Use Cmtbhe To Death? 32.It Female: 33, Manner Of Dead:
0 skitirea,.,w..Prins. 0 am.+M in Of Out 0 Not Penner e.Pmeneni we.,et No=an 0 Natural O Homicide 0 Accident ❑Pending Investigation
C Yes ❑Probably 0No ❑Unknown a iu;.an,*an nmw,43 Nye m t es 9.b.Deem ❑levee.,n P.p.. Welen Is.e....w 0 Suicide 0 Could Not Be Determined
34. Date Of Intury(Month/Day/Year) 35. Time Of Injury 36. Place Of Injury(E.G..Decedents Home.Casoucoon Site,Restaurant Wooded Area) 37. Injury At Won?
0 yes 0 No
9.9.Loratan Of Injury-State 138a.City Or Town 380. Street&Number 33c.Apt.No. 380. Zip Code
39.Desrnoe How Injury Occurred la If Transfer. IM✓y.�.fr.,Oo..t=..�)
41. 5gnature,Of Person Cendybg Cause Of Death: 42.Certifier(Cneck ONy One) lJ
JON M HALL, BY ELECTRONIC SIGNATURE 0 Cend,ing Physician 0 Coroner 0 Heat Deicer
43.Name,Address Ana Zip Cade Of Person Cer:4 m Cause Of Dead: ere.License Number 45.Data Cestfied
JON M HALL ,4015 GATEWAY BLVD.STE.3000. NEWBURGH, IN 47630 01050887A 02/21/2014 •
47. *Alas:
46.Additional Funeral Savior Provider.
48.Signature of Loral Heart Officer 169. For Registrar Only -Date Filed(ManWDay/Year p
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE I FEB 21 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
•
,ei3 State Form 53395 ATTENTION ESTATE:The Social Secunty e is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and mere will be no penalty for refusal:
.(:.- ILO. IVRA-20
(7/05) 9 VOIDIEALTERED,ORYERASED. NOT,VALIDIUNLESS CERTIFIED BY HEALTH DEPARTM: