Death Certificate - Curtis, Martha H_3/7/2016 nalIFISTIIM112200:1 Will:MU a:14191:11111190111:R11:1011MIgro lgllt l714MINIMIUMIT.Y1:1141147:1:11i114\I•s1A:1!.. Uni
"�� INDIANA STATE DEPARTMENT OF HEALTH 10 2 0 2 01
t,( \: CERTIFICATE OF DEATH
Local No 000540 EDR No 000000348410 State No 047427
1.Decedents Legal Name(First.Made,last) la.Maiden Name(If female) 2.Sex 3.thane Of Death 4. Date Of Death(MbnthlDayrrea)
MARTHA HELEN CURTIS GROSS FEMALE 12:02 PM 10/14/2013
61 Months I bays Hours Minutes 02/23/1952 EVANSVILLE, IN
9. Ever N U.S:Armed Forces? ID.If Deaum Omrned In A Hospital: 10a. If Death Owned Somewhere Other Than A Hoopes]
❑Yes 0 No ❑Unknown ®Inpaaent 0 I losppe Faculty 0 Decedents Hone 0 Nursag Home/Long-tern Care Factty
❑Emergency Oceatment OutPatent 0 Dead On Anrvnl 0 Other(Seen-1Y) /
11. FacLty Name(If Not Inst,tcjon,Give Street and Number)
DEACONESS GATEWAY
12.City Or Town,Sate,And Zip Code 13.County Of Death 14. Mental Stasis At Time Of Death
0 Manned 0 Matted,But Separated 0 Divorced
NEWBURGH, IN,47630 WARRICK 0Y^dov.ed ❑Never Marred ❑Unknovn.
15. Sung Spouse's Name 15a.(If Wde)Give Maiden Last Name 16. Decedent's Usual Occupabn 17. Kind Of CmainessAnduswy
JERRY LEE CURTIS " - BARTENDER SERVICE
16. Residence-Sate 18a.County ISO. Ciy Or Town
INDIANA GIBSON OWENSVILLE
180.Street And Number 161 Apt.No. tea.Zip Code lel.Inside CMLlmsts?
10688 WEST 550 SOUTH 47665. 0 Yes 0 No
19. Decedents Eommdrn 20. Decedent Os:aspamc Origin 21. Decedents Race
HIGI I SCHOOL GRADUATE CR GED
COMPLETED NOT HISPANIC White
122.Fathers Name(First.Wale.Last) 23.Mother's Name(First.McKee,Last) 23a.Mothers Maiden Last Name
HAROLD E GROSS MAUDIE IRENE SCHILE SOLOMON
24.Infonants Name 24a.Relationship To Decedent 24b.Mating Address(Street And Number,City,State.Zip Code)
JERRY LEE CURTIS HUSBAND 10688 WEST 550 SOUTH, OWENSVILLE, IN 47665
25.Place Of Disposition I
25a.Method Of Disposition 250.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town.And State
0 Buns 0 Cremation 0 Donato 0 Entombment
0 Removal From State
O Other(Speofyk MAUMEE CEMETERY JOHNSON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Faciry 271. Funeral Home License Wooer.
❑Yes 0 No WERRY FUNERAL HOME INC-POSEYVILLE, 16 FLETCHALL AVE, POSEYVILLE, IN 47633. FH83005655
27o. Signature Of Indiana Funeral SeMce licensee: 27c. License Number(Of Licensee):
PAUL R.WERRY, BY ELECTRONIC SIGNATURE FD08600220
Cause Of Death (See Instructions And Examples) Approximate
23.Part I.Enter The Chain Of Events -Diseases,Irjunes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest.Or Ventricular Fibrillation Without Snowing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A tine. Add Addibnal tines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. LUNG CANCER,NON SMALL CELL 2 MONTHS
Secuentiavy List Conditions. If Any,Leading To The Cause listed On B. CEREBRAL VASCULAR ACCIDENT 1 WEEK
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated a'`ro...m......'a.
The Events Resulting In Death)last C. RHEUMATOID ARTHRITIS YEARS
o...,.o...�....,..on
�, j � RONIC OBSTRUCTIVE es In P PULMONARY DISEASE YEARS
Pan II.Enter Other Sie :Kant donations Conmhu 0 m t No R try I denying Cause Give,In Part I 29.Was An Autopsy Performed? 0 Yes 0 No
1 NONE 30.Were Autopsy Fmung Avalade To Complete The Cause Of Dean?
. 0 Yes 0 No
31. Op Tobamo Use Garbutt To Death? �sp2l��j1(gms�e _UAU 33. Manner Of Death:
0 Yes ❑Probady❑No ❑Unknown IGif ..(..ww..C.l1.lU ❑.. u..•..uo. ❑.� �..•.an .....we....o.n.o... 0 Nature:O Homicide 0 Accident 0 Pm6g n.estgatic'.
0w, et e.ae.....0 a D...Tel ties..0.'e 0 tr+,..,a w.r.awe..m.e..tYr 0 Suicide 0 Could Not Be Determined
34. Date Of Injury(MonodDayrfea) .Time Of Injury 36. Place Of Injury(E.G..Decedents Home,Construction Site.Restaurant Wooded Area) 37. Injury At Work?
y 0 Yes D No
38.loceson Of Injury.seta
GIBSOt*'eeei • AUDITOR 3b' sweet a Number 38c.Apt.No. 38d.Le Code
39.Describe How Injury Occurred 4D. If Transportation In)ury,5 ty
.,e p,,,, ++-. 0th-tse..m
41.Sgnasrre,Of Person denying Cause Of Der: 42.terser(Check Only One)
LEE S.WAGMEISTER, BY ELECTRONIC SIGNATURE 0 Candying Physician 0 Coroner 0 Heath Officer
43. Name.Address And Zip Code OI Person Certt)4:g Cause Of Death: 44.License Number 48 Date Certsed
LEE S.WAGMEISTER ,415 WEST COLUMBIA, EVANSVILLE, IN 47710 01052501A 10/17/2013
46. Add'.ioral Funeral Service Provider 47. 'Arias:
48 Sgnatre of Local Hewn Officer 49. For Registrar Only •Date FOed(MonWDayryearZ
RICKY B?EAGER,VIA ELECTRONIC SIGNATURE I OCT 17 2013 .
' AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
2.6_17 -45-'`r06 cal I. 850. er a )
% State Form 53391 ATTENTION ESTATE:The Social Security e is being recuested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
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