Death Certificate - Wood, Cathy_11/19/2013 rt ; �k.. . , . • , • ,:.._ 109.2887
- -,CERTIFICATE OF DEATH :. ----
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- ,..ts- Local No 000155 •EDR No 000000340860 state No 040222-• • -
I.Decets legal Name(Firm.Mode.Last) 1a. Maiden Name(If famine) 2.Sea 3.Time Of Can'z A. Dote Of Death(MOmuQry/Year)
CATHY WOOD FARRIS FEMALE 06:15 PM 08/26/2013
62 Manor Days Han Menses 01/03/1951 PRINCETON, IN
9. Ever in U.S.Mud Forces? 10.d Dear Occurred In A Hospaat 103. d Dena Occurred Some.seae Other Than A Hospital
❑NOs ice Fao&ty ®Decederts Hare ❑Nurs rN HaneLa alarm Cart Faintly
❑Yes ®No ❑Unknown ❑Inpatient❑Emergency Department Qnoatent ❑Dead n Mural ❑other(spealy)
11. Fein ty Name(If Not tisancn.Give Sweet and Number)
318 WEST WASHINGTON
12.Cay Or Tovm.Slate.And Zo Code 13.County Of Death II. Manta Status Al line Of De=
❑Maned]Mamea,But Seosad 0 Diorcea
OAKLAND CITY, IN,47660 GIBSON ❑HAOcved ❑Neeu MaiAe° ❑Unknown
15.Sasmrg Spaael Name 15a. (if Wde)Gie Maden last Name 16.Decedents Usual Ocmoaton 17.Krq Of&aiessAndsay
FACTORY WORKER
IS.Residence-State tea.County 18c.Cay Or Torn
INDIANA , GIBSON OAKLAND CITY
lec.Street Pad Number led. Apt No. lee. Zip Code 191.bsge City Units?
318 WEST WASHINGTON • 47660 ®Yes ❑No
t9. Decedents Education 20. Decedent Of Hispanic Origin 21. Deceoenfs Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
at Faits Name(First Mode.Last) 23.mother's ers Name(Fist Mode,Last) 23a.Wands Minden last Name
FLOYD ESTEN FARRIS OPAL FARRIS KENT
24.Informant's Name 24a.Rtlapnstap To Decedent 240.mating Aortas(Street Ana Mamba.Coy.State,Zp Code)
MISTY PHILLIPS GRANDDAUGHTER 330 DIVISION STREET APT LOT D, OAKLAND CITY, IN 47660
25.Race Of Disposition
25a-Method Of D postaon 250.Race Of Dispose=(Name Of Cemetery,Cremate.One Race) 25c.Locam•City.Tam.AM State
❑Baal ®Creme= ❑Ddnaton❑Entombment
❑Removal Fran State
❑Omer(Speclyy ALEXANDER MEMORIAL PARK CREMATORY EVANSVILLE,IN
26.Was Corone C.nta ad? 27. Name And Complete Address Of Fungal Fadtty 27a. Fovea Home License Math
❑Yes ❑ ALEXANDER FUNERAL HOME, NORTH CHAPEL, 4200 STRINGTOWN ROAD, EVANSVILLE,
IN 47710 FH19900016
276. Sgnstse Of Indiana Pineal Sevice Leensee: 27c.Lease ranter(Of Li_aee):
JEFFREY W.ALVEY,BY ELECTRONIC SIGNATURE FD29600045
Cause Of Death (See Irish-notions And Examples) Approximate
2E.Pmt I.Enter The Vain Of Events -Diseases.lrqunes.Or Canpacaiors•That Deadly Caused The Deals.Do Not Enter Terminal Events Menial: Onset
Such As Cardiac Mess,Respiratory Mgt Or Vegg4lar Fbnealion Wean Showing The Etiology.Do Na Abbreviate.Enter Only One Cause On To Death
A Line. Add Addled Lines II Necessary.
Immediate Cause(Final Disease Or Condition ResNCng In Death) A. METASTATIC SMALL CELL LUNG CANCERIWITH�e A ES TO THE LIVER 18 MONTHS
Sequentially List Condtsarn. If Any.Leading To The Cause Listed On B. puo etc.u A Cayman at
Line A. Enter The Undelying Cause(Disease Or Injury That Initiated
The Events Restating In Dena)Last C.
Dr a td...•Caress
D.
Part 8.Enter One So But Na ResWOng In The Umaryiig Caste Gen In Part I 29. Was An Autopsy PetcmmM! ❑Yes 0 No
30.Were Auopsy Fndig Available To Canpkte The Case Of Deah? ❑yes ❑No
31.De Tobacco Use Ccanbute To Death? 32. If Female: 33. Manner Of Dean:
0 ❑Embassy❑ ❑ 0 P.•tie...m.,Pr,.. ❑.•>..Am T•••a o.., ❑rH.e-.e....a-r.aei.:°- aw.a 0 Nedal❑Homicide ❑Accident ❑Penang Imestgeson
res No Unknown ❑..,w-.be qy-a ao.,.to m yam e.e.p.e. ❑wem epee,.wee me Ps rm. ❑Suicide❑Coal Na Be Determined
34. Date Of Injury(Mccm/Day/Year) 35.Time Of bi$ry 36. Race Of 4ysy(E.G..Decedents Hoot.Caam,monSae.Res:arait Wooded Ana) 37. bray At Work?
❑Yes ❑No
35.toaten Of Injury-Sae 39a.Coy Or Taws 380. Street&Number 380.Apt No. 30.Zp Code
39.D6cd0e Fox Injury Qcvrtd Q �o.. P...-❑ra.aP.ed
41. Sgnature,Of Peaat Certlyrg Cane Of Death: 42.Cerise(Check Ore eke)
THOMAS MICHAEL WAITS,BY ELECTRONIC SIGNATURE ®Cenlying Physician ❑Can ❑Heath Officer
43. Name.Actress And Zr Code Of Person Cettyvg Cause Of Dean: 44.License Nang 45.Date CatteG
THOMAS MICHAEL WAITS .3699 EPWORTH ROAD, NEWBURGH, IN 47630 01050532A 09/03/2013
46. Addoonal Funeral Service Pmvger 47.-AYas:
48.Signature of Local He=n O@ar: 49. For Registrar Only -Date Died(Mnm/Day/YerF
BRUCE BRINK JR.VIA ELECTRONIC SIGNATURE SEP 04 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
. .- q.,. •
en State Farm 53395 ATTENTION ESTATE:The Social Seapty a is being requested by this state agency in rider to pursue respasibity. Disclosure 4 vGmrary and mere w1L be no penalty for refusal.
i .si• IVRA-20
(7/00) ;VOID I A TEREQOR ERASE 10TIT;VA 0 UNLESS C litlFr D'BY�HEALTH DEPARTMENTV1