Death Certificate - Memmer, Danny L_6/29/2016 1?,.rnt INQIANATSTATE DE RTMENT OFHEALTHY
-;:;it, t t CERTIFICATE OF DEATH 'RESUBMIT -
f ` focal No:0006'3(: EDR No
:000000479822 Legpldame(FesLMidde Laat)..- `000000479822 state rio'05451,8--
eats" .8 ' .�...la. Malden Nam (if Inf.) z.Sea. 3 Time Of Opdh - 1, tMe.Of Death ponNDaylyer)
DANNYLMEMMER lI!
In U.S.Armed Forces) 10.1f Deans Occured In A Hosdtae • PRINCETON, IN `
toe.If Death Occurred i Somewhere Omer Than A tfospital
❑Yes 0 N ❑Unlugnn 0 Inpatient ❑Eme' Department ❑Hospice Fad4ty ❑Decedents Hone Idu u
gency P+dmant 0rtpeuem ❑Dead on AnN°I ❑ ^'"9 arnerLorq.larrn Care FrAtr
I L Fat( (bate pr Na lm ❑oNer(sCetilYl
Y ( 1ErWq Give Street and Number)
DEACONESS GATEWAY
12 fay Or Twn,State,And m Cade
13. Comfy orDeath '4.Marital Status At Tyne Of Death
NEWBURGH, IN,47630 ®Married Married,But Separated ❑Divvced
15.
NEWBURGH,SfIW, IN,
Name WARRICK ❑Widowed ❑New Married ❑unknown
15a.(II wWe)Glve Maiden Last Name 16. Decedent's Usual Occupason 17.Kind Of Business/Industry
MARY MEMMER ANDREANOPULOS OWNER OF TRUCKING
10 Residence•State t8a County COMPANY (TRUCKING
t®. City Or norm
INDIANA GIBSON
lac.Street And Number PRINCETON
t9d. APL No. 18e. ➢p Cade 181 Inside City Lana?
2720 EAST 250 ROAD SOUTH
19 Decedents Educates" 47670 ❑Yes ®No
HIGH SCHOOL GRADUATE OR GED 20. Decedent Hispanic Origin 21. Decedent's Race
COMPLETED NOT HISPANIC
22.Father's Name(First Weddle,Last) White
23.Mother's Name(First,Wide.Last)
239.Mother's Afalden Last Name
ELMER MEMMER CATHERINE MEMMER
-
21,InfamunYS Name 24a.RelasonsNp To Decedent 24b.Mating Address (Street And Number,City.State,Zip Cale)
KIESEL
MARY MEMMER WIFE 2720 EAST 250 ROAD SOUTH, PRINCETIN�7AV0 ED
zed.Method Of Ohaosltim 25.Piece Of Disposition [[[ ./
25b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location.
❑Burial 0 Cremation ❑Donason❑Entombment Coy.Toren,And State
❑Removal From State 2
❑Other(Specifyyy EVANSVILLE CREMATORY I JUN 2 9 2016
26'Was Coroner Contacted? 27. Name And Complete Address Of Funeral Fafdry EVANSVILLE, IN
❑Yes ®No
27a.Funeral Meese lkrnber,J
STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648
27b. Signature W Indiana Funeral Service Licensee:
ANDREA LYNN VINCENT, BY ELECTRONIC SIGNATURE 27c. License NUmt818� OU l Y AUUI I UK
Cause Of Death (See Instructions And Examples) IFD21400005
28.Pen L Enter The Chain O/E any .Diseases,Injuries,Or Complications.That Dlrecty Caused The Death.DO Not Enter Terminal Events
Such As Cardiac Arrest.Resdrdl Artesl.Or Ventricular Fibrillation Without Showing The Etiology. Apprealmate
A Line. Add AOditWl Lines a Necessary. 9 orgy.Do Not Abbreviate.Enter Only One Cause On Interval: Onset
To Death
Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIAC ARREST
Daryl,•Cenee ee oh 10 MINUTES
Sequentially List Conditions, If Any,Leading To Tne Cause Listed On B. MULTIPLE ORGAN SYSTEM FAILURE
Line A. Enter Tne Uneenying Cause(Disease Or Injury That Initiated oat.<Ia a,. , 12 HOURS
The Events Resulting In Death)Last on
C. SEPTIC SHOCK
Dv. to.a.4 ..,,.ors 12 HOURS
D. ISCHEMIC BOWEL
Pan II.Enter Otherponsrant Condtions Contributing to Death But Not Resulting In The Underlying Cause Chin In Part I 12 HOURS
28. Was An Autopsy Performed?
PERIPHERAL VASCULAR DISEASE 30. Were Autopsy Finding Avaeade To Complete 0 Yes 0 No
The Cause Of Death?
❑Yes ❑No
31. Did Tobacco Use Contribute To Death? 32. II Female:
®alp ❑ ❑Dan-e,..,a .e..,r.., .n-,u„•- 33. Manner Of Death:
Probably ❑Onirpwrm ❑^ DDR. ❑...mete De Powerwoe N rnDone 0 Natural
❑eeeerieseeepierDn. r•..e.s,.o... ❑Comkbe ❑etpdent ❑Pergingtnrestgaeon
)r. Dale Of unjury(McnvuVayircr) 35. Time CIIr injury ❑upiry(v..e,.ecev,ire entree ❑Suicide Could Not Be Determined
36. Place Of',wry(E.G.,Decedent's Home.Construction Site,Restaurant.Wooded Area) 37.Injury Al Wand)
38.Lennon Of Injury.State
36a.City Or Town 36e. Sweat d Number Yes ❑No
Sac.Apt No. 38d. Zto Code
30.Describe How InFvy Occurred
aD m Tranaponatfon tr{ury, 7
41.Signature.Of Centro";Cen3 Cause Of Dean: f
DAVID T.HARRIS, BY ELECTRONIC SIGNATURE 4z. Certifier omy One)
13,NYne,Address And Zip Code of Person Cemfyig Cause or Death: I ®Cedhyl^9 Physician 44.Ll ❑Corner ❑Heath Officer I
44,License Number 45.Date Caned
DAVID T.HARRIS , 519 HARRIET ST, EVANSVILLE, IN 47710
ddLmy Funeral son d Provider. 01055444A 11/20/2015
16. A
n. 'Aides:
1&Signature of Local Health Officer: g5
RICKY B YEAGER,VIA ELECTRONIC SIGNATURE (40. For Registrar Only .Date FIIed(Monmmaynearp
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) NOV 20.201 S _ _
'19 i VSY2013
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Slate,Form 53395 ATTENTION ESTATE The Smal Severity 4Is being requested by this stale agency in order to:pursue responsibisly Disclosu a is ountary and there will barn penalty for refusal
.YYAR N'Iw16 ORIGINAL DOCUMENT HAS AMULTICOLORED@ ACKGPDUlD ON SPECIAL WHITE SECURFTY PAPER•AND THE GREAT SEAL OF THE STATEQF INDWJA ON BACK THAT'
❑� G•.TURNS FROM ORA.NGE_TO YELLOW WHEN RUBBE0.ORIGINALUOCUMENT.HAS HIDDEN VOID ON FRONT THAT APoreeern.e...-..,._..__ _