Death Certificate - Johnson, Wayde_5/17/2013 f.__.t i -, i�1- I - I1 -.A ,- 1
897908
i&,lam`, , , e CERTIFICATE OF DEATH
� ''' Local No 000085 EDR No 000000322753 State No 022338
\'J
1.Decedents Legal Name(Fist/Addle.Last) la. Mader Name(It female) 2.Sea 3. Tune Of Dean a. Date Of Dean(MpmWOayfyear)
WAYDE E JOHNSON MALE t 05:48 PM 05/07/2013
53 Mons Days I Hgrs MtVes .
❑Hospice Fealty ❑Decedents Horner '❑Nursing Horne/Lag-tern Care Fact y
❑Yes El No 0 Unknown ❑Inpatient ®Emegency Department Wmatent ❑Dead on Arrival ❑Other(Speedy) �':
-
11. Facility Name(If Nor mWUatn,Give Steel and Number) i - •
GIBSON GENERAL HOSPITAL .
12.CM Or Tam.State.Ara Lp Code 13. County Of Death - -, 14. Mamal Status At Time Of Death
❑Marred❑Married,But Separated ❑Divorced
PRINCETON, IN,47670 GIBSON i ' ❑Waal ®Never Marled ❑Unknown
15.Sunning Spouses Name 15a. (If Wde)Give Maiden Last Name 16. Decedents Usual Octupanon 17. Kind Of Buvnesvinausvy
LABORER BAKERY
It. Residence-State t8a. County 1ea. City Or Tan
INDIANA. GIBSON PRINCETON
I8c. Sweet And Number 18d. Apt No. lee. Lo Code let.Insole Citylimes?
205 DELAWARE STREET 47670 ®Yes ❑No
19. Decedents Educator 20. Decedent Of Hispanic Ongin 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White -•
22.Fathers Name(First Made,Last) 23.Mothers Name(Fast,/Addle.Last) 23a.Mothers Maiden Last Name
ROBERT JOHNSON ELIZABETH JOHNSON GRAPER
24.In nrants Name 24a.Rsatbnsnp To Decedent 24b.Mating Address(Sweet And Number,City.State.Lp Code)
SUSIE JOHNSON SISTER 1905 2ND AVENUE,TERRE HAUTE, IN 47807
25.Place Of Discos:ion
25a,Method Of Dspostor 250.Place Of Disposition(Name Of Cemetery.Crematory.Omer Race) 25c.Lacatdn-City,Tpvm.And State
®Brutal ❑Cremavon ❑Donation❑Entombment
❑Removal From State
❑Other(Spemyk SOMERVILLE CEMETERY SOMERVILLE, IN
25.Was Coroner Contacted? 27. Name And Candete Address Cf Funeral Faaity 27a. Funeral Home Lase Number.
❑Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST.. PRINCETON, IN 47670 FH83005671
27c. License NmM(Of Licenseek
273. Signature Of ndrarM Funeral Sauce Licensee: (
JOHN W WELLS . BY ELECTRONIC SIGNATURE FD01009940
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Crain Cf Events -Diseases,kjuries.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest.Respiratory Arrest.Or Ventncvlar Fibdiation Without 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 Condition Resting In Death) A. CARDIAC ARREST 2 HOURS
ow w io 4,4 c4.-.www •oh
Sequentially List Conditions. If Any.Leading To The Cause Listed On B. END STAGE RENA DISEASE p..w o rye m 3 YEARS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Lau C. UNCONTROLLED DIABETES 4 YEARS
_ o..io A..r- 44 on
D.
Pat II.Enter Other Sifcant Conditions Conniption to Dean But Not Resultrg In The Underlying Cause Gun In Pan I 29.Was An Autopsy Performed? ❑Ye5 0 No
CHRONIC OBSTRUCTIVE PULMONARY DISEASE 30. Were Autopsy Finding Available To Complete The Cause Of Death? ❑Ye9 ❑No
31. Da Tooacdo Use Cortaute To Dean? 32. It Female: 33. Manner Of Deem:
❑' we..w .e...... ❑w.„.Ar..or own ❑' 'wor Se 4.4. w4.. om or tsar, ®Natal❑Homicide ❑Accident ❑Pendrg investigation
®Vey ❑Probably❑No unknown
❑..iw.a.,t suP......a pw.Te, tan 0.a ❑tinbat .o..+w.,.n.Piens. ❑Suicide Could Not Be Desrrvned
34. Date 01 Injury(MmtYDayfYear) r 35. Time Of Injury (36. Place Of vyuty(E.G..Decedents acne.Construction Site.Resaurant Wooded Area) 37.Petry At won?
❑Yes ❑No
38. Locaton Of Injury-State '39a. City Or Town 1 380. Street b Number 38c. Apt.No. 38d. Zip Code
39. Describe How Injury Occurred . ❑m I.f wTransco-Jot�Inrjp wy LI°iy.
w, ❑ow.lsal
-
41. Signature, Of Person Cer4yag Cause Of Dean: _ 42.Center(Check Only One)
KAWABENA OWUSU-DEKYI , BY ELECTRONIC SIGNATURE • • ®CenBywrg Physldan ❑Corner ❑Haan Mow
43. Name.Address And Zip Code Of Person Cendwg Cause Of Death: 44. License Number 45. Date CenEed
KAWABENA OWUSU-DEKYI , 1808 SHERMAN DRIVE, STE.2209, PRINCETON, !N 47670 01070201A 05/10/2013
46. Addtmal Funeral Serene Pmriden 47. 'Akas:
48. Signature of Local Helm Oftcec 49. For Regletrer Only -Dawned(Mon1VDaylYearF
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE MAY 10 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
_`w'r'ye
1 State Form 53395 ATTENTION ESTATE:The Social Security a is being requested by this state agency r.order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
:c: yi (7ros) ®aralu(2tuii:(iml:ai:14.41114;111 CUM nmIMIISIayanal a:I/111:rn10:116u;u