Death Certificate - Galbraith, Ronald G_11/21/2013 THIS IS AN OFFICIAL COPY OF RECORD OF DEATH.,ORIGINAL COPY ON FILE'ATINDIA A- TATE DEPART E T,i T `-a
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,='r INDIANA STATE DEPARTMENT OF HEALTH 7 8 3 6 7 8
1 i CERTIFICATE OF DEATH
&it Local No 002135 - EDR No 000000229559 - State No 050563
1.Decederls Legal Name(First MApe,Last) I& Maiden Name (II female) - 2.Sex 3. Time Of Death 4. Date Of Death(MorvnRlayY'ear)
RONALD G GALBRAITH MALE 07:55 PM 11/06/2011 -
10.If Death Ocarred In A Hospal: 10a. II Death Ocarted Somewhere Other Than A Hospital
0 Hospice Facety 0 Decedents Hare 0 Nursing Herne/Long-term Care Facility
0 Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Department Outpatent 0 Dead on Arrival D Og,e(Specify)
11.Faulty Name(If Not Instpnph Give Street and Number)
DEACONESS HOSPITAL INC
12.Cry Or Town,State,And Zp Code 13. Comb Of Death 14. Manta Status At Time 01 Dead
0 Named 0 Marred,But Separated 0 Divacad
EVANSVILLE, IN, 47747 VANDERBURGH 0 W adwed 0 Never Mamed 0 Unknown
15.StrviW=Spouse's Name 15a. Of VAIe)Give Maiden Last Name 16. Decedents Usual Occxpa•,pn 17. Kind Of Busuessllndustry
LOIS GALBRAITH STEINMAN RETIRED ENGINEER RAILROAD
18.Residence-State lea. County t5C. Gry Or Toxin
INDIANA GIBSON OAKLAND CITY
18c.Sweet And Number led. Apt No. 18e. Zip Code let.Inside City limn?
581 SOUTHST.RD.57 ROAD 47660 -y D Yes 0 No
19.Decedents Education 20. Decedent Of Hispanic Dugan 21. Decedents Race
8TH GRADE OR LESS NOT HISPANIC White
22.Father's Name(First Midde,last) 23.Misters Name(First Middle,Last) 23a.Mother's Maiden last Name
WILLIAM GALBRAITH HAZEL GALBRAITH EDRINGTON
24.Ireonnares Name 24a.Reat:natrp To Decedent 24b Mat=Address (Street And Number,Cry,State,Zip Code)
BILL GALBRAITH SON 581 SOUTHST.RD. 57 ROAD,OAKLAND CITY, IN 47660
25.Place Of Dispose=
25a.Method Of Diapovam T 25b.Race Of Disposibn(Name Of Cemetery.Crematory,Other Race) 25c.Locator-Cry.Town.And State
0 Binal 0 Creme.= 0 Donators 0 Errtaaomen*
0 Removal From State
0 Other(Speck): MONTGOMERY CEMETERY OAKLAND CITY, IN
26.Was Coroner e
Contacted? 27. Name Ana Complete Address Of Funeral Faoty - 27a. Funeral Home license Number
®vas ❑No LAMB BASHAM MEMORIAL CHAPEL, INC.,226 E.WASHINGTON STREET,OAKLAND CITY,
IN 47660 FH83005312
275. Signature OI inga s Funeral Service licensee: 27c.License Number(Of licensee):
JERRY LEE BASHAM , BY ELECTRONIC SIGNATURE FD01016589
Cause Of Death (See Instructions And Examples) Approximate
28.Pan I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Dirac*Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest Respiratory Arrest Or Ventricular Fibrillation Wthoul Snowing The Etiology.Do Not AObrevate.Enter O,*One Cause On To Death
A lint Add Adana!Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A ACUTE RESPIRATORY FAILURE MINUTES
Si.ate•.•ce.•a.•tu 0e
Sequentially List Conde s, If My,Leads=To The Cause listed On 8. MULTIPLE BLUNT FORCE TRAUMA a.n aa•co...s ore HOURS
=
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. MOTOR VEHICLE ACCIDENT _ HOURS
Di.a ea Y•co,to
D.
Pat IL Enter Other Sim:ficant Cc dr+dns Contributing to Dean 8th Not ResLong In The Underlying Cause Grin In Pan I 29.Was M Autopsy Pertomee? 0 Yes 0 No
WA 30.Were Autopsy Finding Available To Complete The Cause Of Dean? ®Yes 0 No
31. Did Tobacco Use Conmbute To Death? 32. If Female: 33 Maurer Of Death:
❑Yes ❑Probably®No DmFrlpwn D w4 w.s...v a t., a r••. 0 n.a,a iir.aam 0 w w.r.tt ea"vowel Wawa be.aam 0 Natal 0 Homicide 0 Accident 0 Pemtdng NVestgabcn
El"... K w P.orr 4 Orr.Tr' kn.nen 0 •w.e,.4wt-a....0- 05udde 0 Ca*/Not Be Deamured
34. Data Of Injury(MendVDayNean) 35. Tone Of Injury 36. Race Of Injury(E.G..Decedents Home.Consovl]pn Sate.Restaurant Wooded Area) 37.hitt)At Wok?
11/05/2011 16:30 STREET D Yee 0 No
38. Locaton 011njtay-State 38a.Cry Or Town 36b. Street&Number 38c. Apt No. 38d. Zip Code
581 SOUTH STATE ROAD 57 COUNTY ROAD
INDIANA OAKLAND CITY 125 ROAD SOUTH 47660-0000
39. Desoto How Injury Occurred 40. It Tra toonatm hr.*. Ow..severs
o^rtear t 0s. ter. LJ°•e•
MOTOR VEHICLE ACCIDENT
41. Signature. Of Person Candy=Cause Of Death, 42.Ceufier(Check Only One)
ANNIE E.GROVES, BY ELECTRONIC SIGNATURE 0 Candying Physician 0 Coroner 0 Heath Officer
43.Name,Address And Zip Code Of Person Catty=Cause Of Death: 44. License Number 45.Data Ce taSd
ANNIE E. GROVES , 201 S. MORTON AVENUE, EVANSVILLE, IN 47713 NONE 11/18/2011
46.Addmmal Funeral Service Provider. 47. 'Akas:
48.Signature of IoW Heat Of5cer. 49. For Registrar Only -Data Filed(Monti/Day/Year):
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE NOV 18 2011
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
T'n
yA State Farm 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal
NRA-20
: / (7/05)