Death Certificate - Riddle, Charlotte F_7/13/2015 . 44k---.7fitWak. -Wt:Tr-Zillin-nrv..-.4ft-, n-WitaillIallUelairla•pargregri"..51 7r7V41....p c.....,ff a.,.. likreLrit•...a. rwmatvisi
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4: CERTIFICATE OF:DEM FI '‘. t. .t ; •7 •, ---,, ; ; :7 .: ..i k,,, .:' .„.
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Looal-No 001.367 -:.„ t,' ; .k ,..E6R-N0'000000455204.t-,-...,:r.i sthte.r40‘030234.
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,.Decedent's Legal Name.(First,mae.Last),,,....-' ,,,•\._. ,,m,....-- -,..122,Maiden Name'(If temale)....,.„1:,., t,,, .:-7 Sex,_, •-• ,.„) Time Of Death...,.,,- _4. Date Of Death(Mn/Dontayfyeep,
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CHARLOTTEF'RIDDLE :: s---.N. t -, i .: *l ...'"-<:, ' HALE( :.4.'"--,.,"`.',- $ .. ..,,",PEMALE ,..-'11'.56 PM '..-. ::.-1,e06/22/2015.'7 .:.'""• '',
, : 5 75' : , mcrths.' ; Days '. ! Anus "H" ', !mint4es ",--: ; ''... \
Nursing Huneiling-terrn Care Faulty
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0 Yes-0 No 0 Unknown 0 Inpatient 0 Emergency Department Ormauem 0 Dead an krnvai .0.5.sa.(speay) . .
11.FaciLty Marne(If Not InsteMon,Give Stem and Number)
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• DEACONESS VNA PLUS HOME CARE& HOSPICE
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' 12.Cdy Or;cam.State,And Lp Code ° ' '?- Gang Ol Death 14. Maraal StaMs At Time Of Death • •
• ' . 0 Marred 0 klaMed,But Separated 0 Divorced
• EVANSVILLE, IN,47713 - VANDERBURGH . Wdowed . .0 Neyer Maned 0 Un'Toon
• 15. SunAving Spouse's Name 15a. (11Wfe)Give Maiden Last Name .: , -18. Decedent's Usual Occupation 17. Kind Of BusiressAndusay
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' DAVID RIDDLE . • . , CARE GIVER HOME CARE .
• 18. Residence-State tea. County - EtiCity Or Town
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INDIANA GIBSON . . OAKLAND CITY, - ' . .- -19c. Sheet And Number . lad. Apt No. 18e. Zip Cede lef_ Inside CitY Limas?
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1224 EAST 275 SOUTH - 47660 CI Yes 0 No
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19_Decedents Educabon 20. Decedent Of Hispanic Ongn 21.,Decedents Race
• HIGH SCHOOL GRADUATE OR GED . . ,
• COMPLETED ' NOT HISPANIC - White, •- ' ' . .• •
22.Fathers Name(First Miacee,Last) - 23.Mothers Name(Fist.Middle last) • ' 23a.Momers Maiden Last Name
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GLOVER HALE . . MAGGIE HALE • : SHORE
• 24.Inbrmant's Name 24a.Relationship To Decedent .249.Mang Address (Street And Nteneer,City.State.Zip Code)
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DAVID RIDDLE HUSBAND • . 1224 EASTi275 SOUTH,OAKLAND CITY, IN 47660
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25a.Method Of Dimond:on 250.Place Of()spas-Mon(Name Of Cemetery,Crernamry,Over Race) ! 25c Locaecn-City,Town,And State
0 natal CI Cremation 0 Demean 0 Entarbrnent
0 Removal From State
0 Other(Spear& TOWNSLEY CEMETERY . .. MACKEY, IN
26.Was Canner Contacted? 27_ Name Ana Complete Address Of Reveal Fealty ' ' '• • ' - - • ' '- ' 27e Funeral Matte License Number.
LAMB BASHAM MEMORIAL CHAPEL, INC.,226 E.WASHINGTON STREET,OAKLAND CITY,
0 Yes 0 No
IN 47660 , FH83005312
275. Signatre Of Indana Funeral Service Licensee: . . ' .
. 27c.License Number(Of licensee).
JERRY LEE BASHAM , BY ELECTRONIC SIGNATURE ... . ... , • FD01016589
Cause Of Death (See Instructions And Examples) - . Approximate
28.Pan I.Enter The Chan Of Events -Diseases,Injuries,Or Complications-That DireMly Caued The Death_Do Not Enter,,Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventria.lar Fibrillation Wtnout Shoving 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 STAGE 4 ADENOCAFiCINOMA OF THE LUNG WITH EXTENSION TO THE PERICARDIUM
101,p4•ca,....m.04
• _Sequentially List ConcNicns, If Any,Leading To The Cause Listed On B- Ins min(...•comma.Oft
Line A_ Enter The Underlying Cause(Disease Or Initry That Initiated
The Events Resulting In Death)Last C.
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G.,,,,,o,....A Coran..“Of)
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• Pan U.Enter Other - •-52,cLCLan ond ecns SOntrilxianci to Deaf))But Na Reza:Jig In Inc UndedyMg Cause Givin In Pan I 29:Was An Atacpsy Perfumed?
0 Yes 0 No
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30. Were Attaspsy Fincing AvaiaNe To Complete The Cause Cf Death? 0‘ies 0 No
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31. Did Tobacoo Use Commute To Death? 32. If Female. - , : .•, • ' • • 33. Manner Of Death: •
0 iet P'eru 'riw ent tea' 0 Paiiiitar Tar,a Deem o se(nesnan so nem..?woe.2 psis of lan? 0 Natural 0 Homicide 0 Accident 0 Pendng Investigation
'0 Yes 0 Probably 0 No 0 Unknown . , ,
0 Nc■P■neart arm?...u on,la l ism s.t..,:en. 0 n.,.....,.F.nometwasi nu/mg Yet , 0 Suicide 0 Could Not Be Determined
I 34.Date Of Injury(Month/Day/Year) 35 Time Of Mpg 36•Place Of[nary(E G.DecederYs Horne Catstxt.on Site.Restaurant Wooded Area) 37. !retry At Won.?
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0 Yes- 0 No
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36 Location Virility-:State. 38a. City Or Tom1 38e Street&Number . • •- • 3ac.Apt No. 38d. Zip Code
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39.Describe Haw IrsurY Onennen . 40 if Iransporaaai inply, O.e...Cily:
DC•fteKlent, OPnenve Uncenas Own snot)
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41.Signature.Of Person Certfying Case Of Dean: 42.Conifer(Check Only One)
JULIE K.GERHARDT, BY ELECTRONIC SIGNATURE .. " El Cellinng Physician .0 Coroner 0 Heath°Meer
43.Name,Address And Sp Code Of Person Centying Cause Of Death: ' - 44. License Numbs 45.Date Certified
; JULIE K.GERHARDT ,600 MARY ST:. EVANSVILLE, IN 47713 , . , 01057271A .. 06/23/2015 .
46.Addmonal Funeral Service Provicler. •
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, .. - ••.' • % . . .' ' '49. For,Registrar Only -Date Filed (Month/Day/year):' •••.
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' ROBERT KENNETH SPEAR,VIA ELECTRONICSIGNATURE :•JUN 25 2015..
.„ : , " ..: .L..AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR OFUGINAL) Z !' :.: :. - -
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State Form 53395, ATTENTION ESTATE The Social Seamy#6 being requested by this state agencyin order to pursue resPOnsibility': [planar,Is voluntary end(here will be no penalty to're'usaL I „;- • ..,.:5
\IVAI:IN 14
d. ORIGINAL DOCUMENT HAS A MallCOLORED BACKGROUND ON SPECIAL VVHRE SECURITY.PAPEWM,ID THE GREAT SEAL OF THE STATE OF INDIANA ON BACK TriAT.,'
• TURNS FROM ORANGE-TO YELLOW WHEN RUBBED.ORIGINAL DOCUME ti•aittua FRONT THATAPPEARS WHEN PHOTO COPIED.., ',,. ...j