Death Certificate - Ellis, Mary Jane_1/13/2016 6.1 Y Q'a INDIANA$TATEDEP _ TMENTTOFFIEAETN : '-
(sAfs_- 1 'CERTIFICATE:OF DEATH
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\ 1. Local No 000184 .EDRNo 000000477955 state No 053334 \
Ire Maiden Name al berate) 2.Sex 3 lane Of Death 4. Date Of Death i'MonNDay-feeeC
\ ,I 1 Decedent's Cereal Nacre(FCSt MidGe,Last) ..
MARY JANE ELLIS - • - . NEVILLE - _ •'I FEMALE I :11:55 PM • I 11/07/2015 .
1.
88 Mvi°*< I Dan Harr M="rea • r 0428/1927 I GRANDVIEW. IN
9.EvwnUS.Allred Forces? 10.If Death Om+radmAHmglaL
10a It Dear Owned SOrtx vlleseOM Tian A Hoap'ral
❑Hospice Facility ❑De¢awrs Hate ®Nuasing Harolmp-term Care FacCry
s�,e 0 Yes 0 No 0 Unknown 0 Ines=ere 0 Emegwtci Department alpaoen 0 Dead at Arrival p Emu(Sperly)
1 11.Feat),Name (If Na Lnatt+al,Gtre Street and Number)
r, GOOD SAMARITAN HOME AND REHABILITATION CENTER 13 County a Death Wawa]ova aT<xdDeam
\$ 12.CtY Or'roan Sax.Na Zc Cane 0 Marred 0 Mama&But Seccaated 0 DNacd
GIBBON ®wed p Never Marti% O wean
OAKLAND CITY. IN,47660 isa (11%tte)One Maiden Last me 16.Decoders usua10m9atm 17.Kate al3ssisessAndua,'
15, &swing Spouse's Na
LABORER FACTORY •
el 19. Resuerre-State ISa CwKY let. City Or Town
a
pr INDIANA VANDERBURGH EVANSVILLE led Apt No lea Zip Code 13:.Inside City Limas?
tact Steel AMN tier
0 Yes 0 Nc
7410 TELEPHONE ROAD 47715
ll 19. Decedents Eoneon 20. Decedent Of hispanic Ongit 21. ()ecedents Rase
A HIGH SCHOOL GRADUATE OR GED NOT HISPANIC White
COMPLETED 23.Mothers Name(Fat.MmGe,Lazq 23a.Morse's Maiden tars Name
e 22.Feelers Name(FM Mode.Lasfl
.4
JEROME NEVILLE MAMIE NEVILLE BEIDENKOPF
Si 24.In'ornanrs Name 24a.Relate setp To Deader 24..Nero Address(Steel And Number.Cry,Sae,3e Code)
II a CHARLES HOWARD ELLIS SON 7410 TELEPHONE ROAD. EVANSVILLE.IN 47715
I 25.Place Of Dismsrvm
25a.Method Of Dispoatom 250.Place Of Disms>x(Name Of Cemeery,Crematory.Omer Place) 25c Locator-ay,Thom.And Size
s 0 Bina/ 0 Cremator. 0 Donaom 0 Em.bmem
0 Removal From Sae
• 0 One-(Specify): GARDEN OF MEMORY CEMETERY GENTRWILLE, IN 22a. Ftmaa:home,xelue Number_25-Vies Carnes Comameci 27. Name And Complete Address Of antral Fac:y
D Yes 0 No FULLER FUNERAL HOME INC.. 109 W. HAMMOND STREET. DALE,IN 47523 FH83001295
Z7c. License N'snbes(Of licensee): •
2A.AARON FULLER.BY Se EC licensee:ON I FD29800057
(AARON FULLER. BY ELECTRONIC SIGNATURE
Cause Of Death (See Ire Wcdans And Examples) Aogrdrima:e
trtevat Onset
S5.Pan LErdia Tre ft.R oEtory rest,Or eets-ar ioCaon\thu-TTa:ng The Causec Do Not Ercer nee Terminal Cars Te Death•Sr.
As Cardiac:...es..Respiratory Ares.,Or Vents-Aar FipnYatian\Whcu:Shaavlc The Etrobpy.Do Na Adaevia:e.Enter Only One Case On
E. A Line. Add AdICYal Lines If Necessary.
Immediate Cause(Final Disease Or Cane:.ian Res:YCnc In Death) A. CONGESTIVE HEART FAILURE YEARS
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e
8. ATRIAL FIBRILLATION 5 YF1+RS
g▪ Sequentially List a Uno irs, E Am', (DiLeading To The Case L¢:eC ec r e rem.lutes.-w w
• Lute At Etter The Ug LnDea Cause(Disease Or'Nun:That Initeac
Y
The Evns Rewhny L Deah)less: C.
p+draw.s.�..�=w.
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Ps.IL Ems:Omer 4T-'`Q"fo:tnA^sG-.":id.:ith Death EJ Na Ree1-r5 Lo The U.nde:ryix Cause GisiT L-.Pan I I2c. 1NYS4+�'nsy PedanxC% pYes �''NC 4
'a1 tM11.' 13o. Were AILOY,'Finend Avaiaoie To Complete The Cause Of Der.? 0 Yes 0 No
IIQQ,,
AIZHEIMERS DEMENTIA 11 LEI 1�r 0 a sat 0l Dream:
s1. Did Tobacco Use Ca .o'.te To Death? 32. 1.Female ,n • ` a
p ee m • a„ da,e=,.a.-+•c•,co...va.c 6T Nr_ral❑Resister ❑Amxm ❑P nsnplmesncaar'.
0 Yes ❑Probably 0 No 0 uni-nem p.�,r..a.,t v='.em a o.n I zed.a< ❑Unease t.,.e.= .^a tog see, ❑5.0°c 0 Gaye Not ce Derr nec
3<.Date Of Injury(MYl.Oa.iYnr) 35. Te-e Of IK ty 36. Place Of Ivey(EG.,Dec.eoems home,Ca-sr-urban See,Res a:are%booed 5 a) Sr.LiT N NVxi
JAN1' 32�16 I oyes ❑N
0 39a. Cry Cr Tern I SEE Street S::;tnxt 35c.Apt No. 3Ed.Zip Code
36. ldrzion Otlrj�-Sax I y _
��c.. p-IfTa.paaaLia',Seiy:
17 cexHa eery ad GIBSON COUNTY AUDITOR I p' ° p°� p pin
42.Certifier ICneck Orly Ocx)
g� <t.S9nYua, OtPeHACe:iE+N Cause ELECTRONIC SIGNATURE License tsnber 45 Dane Cod ed
5 43. Name,Address A...=M Code Of Person Crying Cause Cl Death
• TERRY GEHLHAUSEN , 1020 W. MORTON, OAKLAND CITY, IN 47660 02000730A 11/12/2015
46. Additional Funeral Service Provider.
45. For Register Only -Data Fled(MaNDrylyesy:
1-0 <a. Signature of Lm:Heath Mar. I NOV 13 2015
BRUCE.BRINK JR.VIA ELECTRONIC SIGNATURE
. AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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