Death Certificate - Mahan, Meredith M_7/23/2015 S) ,��,. t INDTANi�STAT.E l*P/l1 MEN I UFAE r �� -,."
^Si IL : ` CERTIFICATE,OF DEATH
,A Local:No 004459- ..EDR No 0000004579897c state.No 032584 K_'
DseEent s Legal l.a^e�(F stMaddie Last....^ -� Ala Maioen Name (It fence) 2 Se 3 ,Tone Ot Death <. Dore Ol Dean (MOMAayMea�,. '
0.: MEREDITH MABEL MAHAN ' . `T. ' COLEMAN L z .. .FEMALE - 06:45 PM ` a^07/07-12015-1.,----.."
92 i Maims Dan Horns minute! , )■ l- . 'PRINCETON,'IN. - . -
9-Ever h U S.Armed Faces? 10.If Death Ocuarec In A Hospita: t0a. d Death Ocvrted San w1Mr OOhtt Than A Hosgla
a.r ❑Hospice FeoLty ❑Demde'ti Hoene ®NUrscy Hanel n}term Care Facility
�//`�R� 0 Yes. 0_No ❑Urirorl ❑Inpatient 0 Emergency Departmere W patent 0 Dead on Moral 0 der(speedy)
'� I1.-Party Name(If Na Ins:tuien,Give Street and Ntasber)
RIVER POINTE HEALTH CAMPUS
1 12.City O Tom.Sate,And Zip Cade 13.Canty Of Dean 1<.Matrsl Status At Time Of Death-(�4 ❑Marred[]Married.But Separated ❑Divorced
EVANSVILLE, IN,47715 VANDERBURGH 0 Miaowed ❑Neverwarned 0 unWgwn
33 15.Surviving Spouse's Name 15a. Of W.:e)GNe Maiden Last Name 16. Decedents Usual Occwatwn 17. Kind Of r+iness&nustry
(C�
lO HOMEMAKER DOMESTIC
18. Residence-Sate 18a. Canty lab. City Or Tend
W.
INDIANA VANDERBURGH EVANSVILLE
16c. Street And Number 18d. Apt No. I 18e. Zip Code :et. Inside Crty Lints?
n"4
✓ 0 Yes ❑No
T 3001 GALAXY DRIVE I 47715
19.Decedents Educaton 20. Decedent Of Hispanic Origin 21. Decedents Race
SOME COLLEGE CREDIT, BUT NOT A
DEGREE NOT HISPANIC White
rf
22.Fathers Name(First.Midale,Last/ 23.Mothers Name(Fest Mico!e,Last) 23a.Mothers Marren Last Name
,ALBERT R. COLEMAN EMMA MABEL COLEMAN STEWART
/Yv 24.INormanrs Name 24a.Relatansfip To Descent 245.MaMaim Address(Street And Number,[ay.State,Zip Cooe) .,
O BETTY J ALTHEIDE DAUGHTER 8977 WOODLAND DRIVE. NEWBURGH, IN 47630
Ui25.Pare Of Disposition
25a.Method 01 Dispds:bon 250.Rare Of Disposition (Name Of Cemetery.Crematory.Ones Place) 25c.Iceman-ray,Tway,And State
CC 0 Burial ❑Cremation ❑Donation❑Ercama:'era
IV ❑Removal From Sate
CC ❑Oder(Specify): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN
0 '25.Was Corona Contacted? 27. Name And C omplete Address O!FUnaa!Fealty 27a. Funeral Horne License Number.
W ❑Yes 0 No COLVIN FUNERAL HOME INC.425 N MAIN ST.. PRINCETON, IN 47670 FH83005671
Q 27C Sgnarre Of Indiana Funeral Service licensee: 27c. License Number(Of Licensee):
W RICHARD DEAN HICKROD• BY ELECTRONIC SIGNATURE FD01012153
JCause Of Death (See Instructions And Examples) Approximate
,:-.5c. Pan I.Enter The Chan Of Events -Diseases,Injuries,Or Complications-That Dieay Caused The Dean.Do Not Enter Terminal Events Interval Onset
LL' Surf.As Cardiac Ares:,Reso'vatay Arrest,Or Verrncular Fibrillation Warou:Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
OA Line. Add Additial Lines If Necessary.
O Immediate Cause(Final Disease Or Condition Resultrg In Death) A. ATHEROSCLEROTIC CARDIOVASCULAR DISEASE
a�\llyy��I sale au•cw..w on
Lc Sequereialy List Conditions, If Any,Leading To The Cause Listed On B'
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated a.eTa u.cr..eme on
The Events Resulting h Dem..)Last C.
l Daeto-u•cm..:.+edo
D.
11 1 Pan I1.Enter Other Sion:`cart Condtons Conmbu:n:to Dean But Not Ressnng In The Underyirg Cause Givin In Part I 29. Was An Autopsy Pefxmea? Yes (]No
30. Were Autopsy Fndcg Available To Conplete Inc Cause Of Death? 0 yes ❑No
31. Did Tobacco Use Corm.tsute To Death? 32. It Fertile: 33. Maurer 01 Dean
Yes ❑Probably No (]Unknown
n.e eHem v°`.Peep..' ❑nao're arm a ream 0 ua Aeoet v my s'c'r,pays a ia' 0i Naai210 Hostiote ❑Accident ❑Pendng Investigation
F ❑scimeo. .e,,Pnaw.Coati t.'v'a,cad.sem ❑u-a eewwm wee The Fn tea, ❑5ucide❑Cosid Nx Be Determined
I 3<. Date Of Injury(McnsVOav�Year)
35. Time Of Injury 38. Place Of Injury(E G.,Decedenrs Home,Constr ction Ste,Restaurant,Wooded Area) 37. I,rysay At Work?
❑Yes ❑Hs
38-Loraton 011rywJ-Sate 38a. City Or Torn 320. Street 8NUmtel' 3fie. Apt No. Sad. Zip Code
-j
P39. Desoae How Injury Cce:ieC 40. It Transportation Iry,+ry,Specify!
))) Dce..Transp Q Transportation LJe a pdre.ISPertrt
ki
dl. Signature,Of PersonCervfyng Cause Of Dealt
42.Cem6er(Cner}Ony One)
DANIEL J. NALIN. BY ELECTRONIC SIGNATURE O eemying Physician ❑Coroner ❑Henn orsrer
43. Name,Address And Zo Cm OI Person Certifying Cause Of DeatR
44. License Ratner
45. Date Cen:`.ea
DANIEL J. NALIN . 7750 OAK HILL ROAD, EVANSVILLE. IN 47711 01064687A 07/09/2015
46.Additional Funeral Service Provider. 47. 'Alas'.
49:Signature W Loral Henn O'5cec • . 49. For Registrar Only -Date Film(MondVDayfYear):
.. ROBERT KENNETH SPEAR;VIA ELECTRONIC SIGNATURE . .' - JUL 70 2015_
>) - . - AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) ' -
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(0- Store Form:53395 ATTENTION ESTATE:The Social Seamty e a being requested by ors stele agerry in.order to pursue responsibby. Diirbsure s vol'Mary rid there wl0 be no penay for refusal -
Lim \ WARNING ORIGINAL OOCUMENi HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE,OFINDIANA ON BACK THAT -,J
y[)�,,�. TURNS FROM ORANGE.TO YEU.DW-V HEN RUBBED.ORIGINAL DOCUMENT HAS HIDDEN VOID ON FRONT THAT APPEARS WREN PHOTO CO IED r'