Death Certificate - Meyer, Cheryl_8/9/2013 � � INDIANA STATE DEPARTMENT OF HEALTH�� 108 713 3
i CERTIFICATE OF DEATH
Local No 001458 EDR No 000000335164 State No 034152
1.Decedents Legal Name (First Middle,Last) 1a.Maiden Name (If female) 2.Sex 3. Tune Of Death 4. Date Of Deat(McnWDay(Year)
CHERYL LEE MEYER ANDERSON FEMALE 03:51 AM 07/24/2013
5
•0 Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Department Oufpalen 0 Dead On ARVal 0 Other(Specify)
❑Decedents Hone ❑Nursing Horne/Long-term Care Facihry
❑Other(5persy)
11.Fact"Name(If Hot Insaarauy Gee Street and Number)
DEACONESS HOSPICE CARE CENTER
12.City Or Town.State.And 2,p Code 13.Cony Of Derh 14. Mantra Status At Time Of Deem
0 Marred 0 Marred,But Separated 0 Divorced
EVANSVILLE. IN,47747 VANDERBURGH p Widowed p Never Memel 0 Unknon
15. Survivg Spouse's Name 15a. Of VAfe)Grve Maiden Last Name 16. Decedents Usual Ocmpauon 17. Kik Of BosieSSArCusay
RICKY MEYER WAITRESS FOOD SERVICE
18. Residence-State 18a. County 180.City O Town
INDIANA GIBSON ,FORT BRANCH
18c. Street And Number 18d. Apt.No. 18e, Zip Code 1.81.Inside City Lints?
701 SOUTH MAIN STREET 47648 0 Yes 0 No
19. Decedents Education 20. Decedent Of Hispanic Ongm 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fames Name(First Wide.Last) 23.Matters Name(First Middle,Lan) 23a.Mothers Mahn Last Name
JOHN ANDERSON MARY ANDERSON WOLFE
24.Irbnnans Name 24a.Relationship To Deaden( 24b.Mating Address (Street And Number,City,State,Zip Code)
RICKY MEYER HUSBAND 701 SOUTH MAIN STREET, FORT BRANCH, IN 47648
25.Place Of Disposron
25a.Method Of Dlspositon 25t.Place Of Disposition(Name Of Cemetery,Crematory,Omer Race) 25c.Locaton-CIty,Tom,And State
0 Bridal 0 Cremaon 0 Dcnaam 0 Ertonbment
0 Removal From State
0 Omer(Speay), GOODWINE CREMATION SERVICES PALESTINE, IL
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Faokty 27a. Funeral Hone License Number.
❑Yes 0 No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
27b. Signature Of Indaru Funeral Service Licensee: 27c. License Number(Of Licensee):
ROBERT S STODGHILL, BY ELECTRONIC SIGNATURE FD01024378
Cause 01 Death (See Instructions And Examples) Approximate
29.Part I.Enter The Chan 01 Events •Diseases,Injuries.Or Complications-That Directly Caused The Dean Do Not Enter Terminal Events ' bnervat Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrilnlibn Without Snowing The Etiology.Do Not Abbreviate.Enter Ony One Cause On To Death
A Line. Add Add.tinal Lines If Necessary.
Immediate Cause(Final Disease Or COnddion Resulting In Death) A LUNG CANCER 3 MONTHS
00
Sequentially List Conditions, tl Any,Leading To The Cause Listed On B.
Line A. Enter The Underlying Cause(Disease Or Iryiry That Initiated ware stn acne..
The Events Result»;In Death)Last C
Dwtl tom Ca..ewude
D.
Part II.Enter Omer .- • •i.nn •nnb • •.-am But Not Resulting In The underlying Cause Gen In Pan 29. Was An Autopsy Perfumed? Gyce 0 N
CARDIAC ARREST 30.Were Autopsy Fndng Available To Complete The Cause Of Death? 0 Yes 0 No
31. OW Tbbacoo Use Conmbute To Death? 32. If Female: 33. Manner Of Death:
0 Yes ❑Probably❑No ❑Unknown 0 M9 ma...vane,am 1e. 0 mn..x u re.Of D.am 9 rte a.•w+ea Repawvb.,a lose u am 0 Natural 0 Homicide 0 Amain 9 Pending Investigation
0 meme.,t M...r.r o orete.lwMb.w.m p,,+w..eawer.rw.,tn.Peer... 0 Suicide 0 Card Not Be Determined
34. Date Of Injury(MawvoayfYear) 35. Time Cl Injury 36. Place Of tyty(E.G•Decedents Hone,Carsmn,on Ste.Restaurant Wooded Area) -37. lrytay At VVock7
0 yes 0 No
38. Loobon Of lryury-Stab 38a. City Or Town 380. Street d Number 38c. Apl No. 380. Zip Code
39. Desmte Hoe lryny Occurred 40. If Transpuvim
p Wryly,Specify:
o...oe.. peer,. e
en pp...raee.,I
41.Sgmare• Of Person Cer-tying Cause Of Death- 42.Caned(Check Only One)
LARRY WILLIAM LUTZ, BY ELECTRONIC SIGNATURE ®certryng Physician 0 Coroner p Hem Omcer
43.Name,Address And Zip Code Of Perron Certfyug Cause Of Dean 44, License Number 45.Data Cr Sed
LARRY WILLIAM LUTZ ,802 E.OAK ST..FORT BRANCH, IN 47648 01027538A 07/25/2013
46.Add•xna Funeral Service Provider. 47. 'Akas.
43. Signature of Local Health Officer. 49. For Registrar Only -Date Filed(MOnttfayfYea):
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE JUL 26 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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• State Form 53395 ATTENTION ESTATE:The Social Semny d 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
(7ros)