Death Certificate - Hunt, Nora Mae_5/1/2015 .- %113t°3J t 4 9.r lWall.41.... -/1t?-, -, fl Wa$l-9.c t4sWu ' w'tw:,'.;vii.--nw..w.'Y�-..WE-Wwvva:-n -ais..w:.v...nm-.munve...r_•
/ ",-a. e.r' ` .-INDIANA STATE DE RTMENT OF-HEALTH',
/r �tl :-_ , s ;CERTIFICATE OF DEATH - a 1
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- �/f Local NO c.0002-2 " ,: DR Nos000000444396- state.Nos019730 • . .
1.Decedents Legal Name( est!Addle.Last)" .. , , ' •++' '' 'r.ta. taidenName(It.female)'- - .,." 2•Sexr 3,-Tese Of Death' 4.Date Of Death(Mor.NOayNear)
•T NORA MAE HUNT> : ' 1, .. > , HUNT-' •`'`, FEMALE '' 06:30 PM • /'-'04/17/2615,`-'",
82 limas - Dan' % Hours"` % Mmo.es v . , . : i'PRINCETON,IN . . ,i' -
9. Ever inU.S:Armed Forces? 1D.If Death Occurred In A Hospital: . 10a.:t!Death Occurred Somewhere Other Than A Hospital j
' : : \.. ❑Hospice Faosty .0 Decedent's Home .❑Nursing lbresLag-lain Care Fealty
❑Yes 0 N ❑Un'mowr. 0In;.aient ❑Emergency Depavnent Outpe.ent ❑Dead on Minuet 0 Di (Speofy) '
II.Facility Name(If Not Insrtjoan,Gin Street arc NumM)
DEACONESS GATEWAY
12. City Or Town.State.And LO Code " ' , 13.County Of Death 54. manual Sams At Time Of Death
❑Marred O Marred,But Separated d 0 Dammed
NEWBURGH, IN, 47630 .. WARRICK ❑Widowed ®Never Memel ❑unknown
15,Surviving Spouse's Name 15a.(If Wife)Give Maiden Last Name 16."Decedent's Usual Occupation 9. Kind Of BusOAssllndusby
FACTORY MANUFACTURING
•
18.Residence•Sate lea.County / lab.City Or Town
• INDIANA •GIBSON PRINCETON
19c. Street And Number . - - 18d. Apt.No. 18e. Lp Code 101. Inside OW Limits?
1827 EAST STATE STREET • LOT C 47670 ®rw ❑No
19.Decedent's Education 20. Decedent Of Hispanic Orgin 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
- COMPLETED NOT HISPANIC White .
22.Fathers Name(First!Adele.Last) 23.Mother's Name(Fist Middle,Last) 23a.Mothers Maiden Last Name J
" ELMER HUNT • NILA HUNT RICHARDSON
24.informant's Name 24a.Relationship To Decedent 24b.Maiig Address•(Street And Number.City.State.Zo Code)
MARY LOU WATKINS SISTER . . 6093.EAST 390 NORTH, FRANCISCO,IN 47649
" ace Of DisPoseJon - _
25.M
25a.Method Of Disposition 250.Place Of DeppYton(Name Of Cemetery,Gematay,Other Place) 25°.LoglOn-City•Tom,And Sa's
0 Bural ❑Cremation 0 Donation❑Entombment
❑Removal From State
❑Other(spepyk MT OLIVE CEMETERY . MOUNT OLYMPUS, IN
26.Was Coroner Contained? 27. Name And Complete Address Of Funeral Fay - 27a.Funeral Home License Number
❑Yes 0 N COLVIN FUNERAL HOME INC, 425 N MAIN ST., PRINCETON, IN 47670 _ FH83005671
27b. Signature Of Indiana Funeral Service Licensee: 27c.License Number(Of Licensee)
MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See Instructions And Examples) - Approximate '
28.Part I.Enter The main Of Events -Diseases,Injuries.Or Complications-That Directly"Caueed The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest.Respiratory Arrest,Or Ventnwlar Fibrillation Without Snowing 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 Resulting In Death) A. RECURRENT SEVERE RESPIRATORY FAILURE WITH ASPIRATION PNEUMONIA B DAYS
oa.eto.A.Ac a....n04
SEVERE METABOLIC AND RESPIRATORY ACIDOSIS FROM RESPIRATORY FAILURE AND
• Sequentially List Conditions, H Any,Leading To The Cause Listed On B. CHRONIC KIDNEY DISEASE - 8 DAYS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated Melo..Are...,.F.m
The Events Resulting In Death)Last C. HYPERNATRE MIA AND HYPERCHLOREMIA 5 DAYS
• d.eta..-A Owww.n.dn
D. CHRONIC DYSPHAGIAAND RECURRENT ASPIRATION CHRONIC
Pan II.Enter Other Sicrsirant C,'4sonsConthWin°to Death But Not Resulwg In The Underying Cause Given In Pant 29. WasM Autopsy Performed? O Yes 0 No
ACUTE ON CHRONIC KIDNEY DISEASE.CHRONIC SYSTOLIC CONGESTIVE HEART FAILURE,SEPSIS WITH 30:Were-Autopsy Finding Awsade To Complete Tne Cause Of Death?
• PNEUMONIA AND URINARY TRACT INFECTION TREATED.PAROXYSMAL ATRIAL FIBRILLATION - ' ❑Yes ❑No
31.Did Tobacco Use Conthbute To Dean? 32.If Female: • 33. Manner Of Dean: •
❑Yes ❑Probably®No ❑unknown
0 Na w.we vv4..e.e r.. 0 M1.e•.1.At Ten.ofo.w E)r.et M eac..P.w We..2 own a oe.. 0 Natural❑Homicide 0 Accident ❑Pending Investigation
0.0 Rent(ea Powwow 0 awn i.t,...lab Now 0 t.:A.e ee,.e:,tw.a raw e.m v... ❑Suicide❑Could Not Be Determined
. 34. Date Of lnjury(MondhDay/Year) 135. Tune Of Injury 36. Place Of Injury(E.G.',Decedents Home,Canssuclion Bite.Restaurant Wooded Area) 37. Injury At Wort?
❑Yes ❑No '
38.Laaton Of lna,ry-State 38a.City Or Town 38th. Street 4 Number 38c. Apt No. 380, Zip Cabe
39. Desrnce How Injury Oca,,ned 40 If Transportation Injury._5 Y
a t. Sgramre,Of Person Cen.dying Cause Of Dean: 42. Ceruder(Cnec4 Only One)
• RAMA DEVI CHILUKURI .BY ELECTRONIC SIGNATURE • _ 0 Cerrtr4ng Physician ❑Coroner , ❑Heath Otter
43.Name.Address And Zip Code Of Person Certfyig Cause Of Death: 44, License Number 45. Date CeR:<d
1
RAMA DEVI CHILUKURI ,600 MARY ST, EVANSVILLE, IN 47747 . . . 01058093A 04/23/2015 .
46. Ade.tonal Funeral Service Provider- - 47. 'Aia:
48.Sgnature of Local Health Officer. _ . " 49. For Registrar Only •Date Filed(MOnoVDayivear)
' RICKY B YEAGER,VIA ELECTRONIC SIGNATURE .. _ - - • APR 23 2015
S.AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)' ) , 2. . , , - i
}t N 4 /' se .tier
Sate Form 53395 ATTENTION ESTATE The Social Secunly a is being regUested by this state agency in order krde.:1,to pursue respons bltiy Obdostire is voluntary and there will be no penally for refusal•WARNING.."1°'FROM ORANGE TOYELLOWW EENRUBBEDOOGNAOOOCUME THASHDDENYODONFRW HAT.APTFARSYMENPHOT COPEO�AONBACKTHAT