Death Certificate - Powell, Bill E_4/16/2014 .. it J+ `(% }j 1� ).] INDIANA STATE DEPARTMENT OF HEALTH 802059
a u CERTIFICATE OF DEATH
' "! Local No 000006 EDR No 000000372267 State No 009384
1.Decedents Legal Name(Fest,Middle,Last) 1a.Maiden Name(Ii female) 2.Sex 3. Time CM Dean a. Date Of Dealt(Monr/DayNear)
BILL EDWARD POWELL MALE 09:33 AM 02/26/2014
Forces? 10.11 Dean Occurred In A Hospital: •10a'1(Death Occurred Somev.Mre Other Than A Hospital
0 Hospice Fac5y 0 Decedents Home 0 Nursing Hcenellmgterm Care Facay
0 Yes 0 No 0 Unknown 0 Inpatient 0 Emergercy Deparnment OuVadenl 0 Dead on Arrival 0 Over(Spaeth')
11.teary Name(II Not Institution,Give Street and Number)
10423 SOUTH COUNTY ROAD 425 EAST
12.Coy Or Town,Sus,And Zip Code 13.Couny OI Dean 14.Manta'Stave At Time Cl Death
0 Married 0 Mailed.But Separated 0 Divorced
STENDAL, IN,47585 PIKE 0 Yndo a 0 Never Marled' ❑Lee--wn
•
15.Sunhirg Spouse's,Name 15a. (If Wte)0We Maiden Last Name -- 16. Decedents Usual Occupation 17. Kind Of Busieaairqustry
LAVON POWELL SNODGRASS OWNER OPERATOR DRIVEWAY SEALING
18:Residence-Slate lea. County lab. pry Or Town
INDIANA PIKE STENDAL
13.Street AM Number - - - 160. Apt.No. 18e.bp Code 191. Inside 0y(entry?•
10423 SOUTH COUNTY ROAD 425 EAST 47585 ❑ves 0 No
19.Decedents Education 20. Decedent Of 14spanc Origin 21. Decedents Race
9TH- 12TH GRADE; NO DIPLOMA NOT HISPANIC White
22.Fathers Name(First Made,last) 23.Mothers Name(First,Middle.Last) 23a.Mothers Malden Last Name
VICTOR POWELL GENEA POWELL GILBERT
24.Informant's Name 24a.Relationship To Decedent 24b.Malang Address (Street And Number,City.State.Zip Code)
LAVON POWELL WIFE 10423 SOUTH COUNTY ROAD 425 EAST,STENDAL, IN 47585
25.Place Of Disposition
-
25a.Method Of Disposition 25b.Place Of Dsposieon(Name 01 Cemetery,Crematory,Other Pace) 25c.Location-Ciry,Town.And State - '
0 Bural 0.Cremauon 0 Donation G'Entom d bme '
0 Removal From State
0 Other(Specify): LYNNVILLE CEMETERY LYNNVILLE, IN
26.Was Coroner Contacted? 27. Name And Compete Address Of Funeral Petrify 27a, Funeral Home I can se Number.
0 Yes ❑No KOEHLER FUNERAL HOME INC, 304 E. MAIN STREET, BOONVILLE, IN 47601 FH83000477
27b. Signature Of Indiana Funeral Service Licensee: 27c. license Number(CM Licensee):
RICHARD HEADY DILLINGHAM , BY ELECTRONIC SIGNATURE FD01005784
Cause 01 Death (See Instructions And Examples) Approximate
28.Pan I.Enter The Cnaln Of Events -Diseases,Injuries.Or Complications-That Dreary Caused The Death.Do Not Enter Terminal Events interval: Onset
Suds As Carded Arrest,Respiratory Arrest,Or Ventricular Fibrillation Wnhout Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Addtinal Lines It Necessary.
Minedrate Cause(Final Disease Or Condition Resu Ili g In Death) A ACUTE LYMPHOBLASTIC LEUKEMIA• 1 MONTH
nIf 4.ce.e.o .Ca
•Sepuen-iaRyUstCondtios, H Any.Leading To The Cause Listed On R'
om e p.m.deeebewee ar
Line A Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C
ate to....vm..e ors .
D.
Pan 1.Enter Ogler$k ni-ant Coecitions Contdburino to Deeh BLit Not Resulirg In The Under/Ong Cause Chin In Pan I 29.Was An Autopsy Redeemed? 0 Yea ®No.
30.Were Autopsy Figirg Avatade To Complete The Cause Of Death? 0 Yes 0 N.
31.Dd Tooacoo Use Contribute To Death? 32. II Female: 33. Maurer CM Death
❑Yes ❑PrdaNy®No ❑Unknown
0 M1 PijV wain Pei Y., 0 P..>an.iTr.a Den 0 ra Pncort ma 8.9.8wwe e2 D.,,o.D.n 0 Natural 0 Homdde 0 Accident
Pending investigation
0.-P^S^rt But P.-pm 43 owl To r ewe Son 08.11 0 Dee...1Pnewvemne P.ire. 0 Weide 0 Could Not Be Detamune7
34.Date CM Injury(Ma-M/Day/Year) 35.Tine DI Injury 36. Race CI injury(EG.,Deceoenrs Home,Construction Site,Restaurant,Wooded Area) 37.Injury Al Work?
❑Yes 0 No
38.locaban Ol Injury'.State 38a.City Or Town 38b. Street 6 Nneer - 38c. ApL No. 38d. Zip Code
39.Describe How Injury Occurred a0. II Transporaaon Injury,S y:
Goen.cc One.gw Uw.❑o..'R..,1
41.Signature.Of Person CeityYg Cause Of Deatt 42.Cenher(Check Ddy One)
ANTHONY W STEPHENS, BY ELECTRONIC SIGNATURE 0 Certifying Physician 0 Coroner 0 Heath Officer
43.Name.Address And Zip Code Of Person Cerulai g Cause CI Death 44.ticerse Number 45. Data Certified
ANTHONY W STEPHENS , 3699 EPWORTH ROAD,NEWBURGH, IN 47630 01040406A 02/28/2014
46. Additional Funeral Service Provider, 47. 'Alas:
88.Signatures Local Heath Of5cen 49. For Registrar Only -Date Filed (monWDay/Year)
HONESTO K FENOL,VIA ELECTRONIC SIGNATURE MAR 03 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
a6 - 30-a`i- loo-moo. 536-0O1
- Sale Form 5l9 I1'TENTION ESTATE:The Social Security a is being requested by this state agency in order to pursue responsibiSy. Disclosure is voluntary and there wit be no penny for refusal_
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